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.

Expert Opinion: Use of sodium glucose co-transporter type-2 inhibitors in South Asian population -The Pakistan perspective.

Sodium-glucose co-transporter type 2 inhibitors (SGLT 2- i)are increasingly being used in the management of type 2 diabetes mellitus (T2DM). With the novel insulinindependent glycosuric action, these agents help to attain glycaemic goals by lowering HbA1c and fasting blood glucose. In addition, these agents improve metabolic control in diabetes and ameliorate comorbidities like obesity and hyper tension. Beneficial effec ts on cardiovascular outcomes have been a key attraction for physicians. These agents are used alone or in combination with oral antidiabetic agents and insulin to attain glycaemic and metabolic targets. A major disadvantagewith these agents is the increased risk for genital andurinary infections. When used in appropriate settings, there is no additional increased risk of hypoglycaemia or volume depletion with these agents. Available evidence suggests good efficacy and safety of these agents in diabetes management. The easy and convenient oncedaily dosing should be customized according to patient needs and glycaemic profiles.

Dietary habits and practices of type-2 diabetic patients in a tertiary care centre of Islamabad, Pakistan.

OBJECTIVE: To determine the relation between food intake and diabetes control. METHODS: This cross-sectional study was carried out at Department of Medicine and Endocrinology, Shifa International Hospital, Islamabad, Pakistan, from July 2016 to February 2017, during which type-2 diabetes patients were interviewed using a structured questionnaire. Demographics, intake of high glycaemic index foods consumed in each food group, and general dietary practices were assessed by means of number of meals per day and adherence to the dietary plan. Glycated haemoglobin A1c values were recorded as well. SPSS 21 was used for data analysis. RESULTS: Of the 180 patients, 100(55.6%) were taking three meals a day. Besides, 108(60%) had an income >Rs50,000. Moreover, 127(70.6%) patients were not aware of the type of diabetes, while 117(65%) patients had high glycated haemoglobin levels. Furthermore, 148(82.2%) made a change in diet following diabetes diagnosis, while 168(93.3%) had recommended food available in their house, and 65(36.1%) followed a strictly-recommended dietary schedule. A statistically significant association was found between the consumption of different desserts/sweets and glycated haemoglobin levels (p=0.008) followed by fruit intake like mangoes (p=0.004) and grapes (p=0.02). CONCLUSIONS: There is a need to educate diabetics regarding diet management in terms of glycaemic index of foods.

Update to South Asian consensus guideline: Use of newer insulins in diabetes during Ramadan Revised Guidelines on the use of insulin in Ramadan.

This guidance is an update to the South Asian Consensus Guideline: Use of Insulin in Diabetes during Ramadan, published in the Indian Journal of Endocrinology and Metabolism in 2012. A five country working group has collated evidence and experience to suggest guidelines for the safe and rational use of insulin degludec (IDeg) and insulin degludec aspart (IDegAsp) during Ramadan. The suggestions contained herewith are based on the pharmacokinetic and pharmacodynamics properties of these novel insulins.

Leveraging Deep Learning for Designing Healthcare Analytics Heuristic for Diagnostics.

Healthcare Informatics is a phenomenon being talked about from the early 21st century in the era in which we are living. With evolution of new computing technologies huge amount of data in healthcare is produced opening several research areas. Managing the massiveness of this data is required while extracting knowledge for decision making is the main concern of today. For this task researchers are doing explorations in big data analytics, deep learning (advanced form of machine learning known as deep neural nets), predictive analytics and various other algorithms to bring innovation in healthcare. Through all these innovations happening it is not wrong to establish that disease prediction with anticipation of its cure is no longer unrealistic. First, Dengue Fever (DF) and then Covid-19 likewise are new outbreak in infectious lethal diseases and diagnosing at all stages is crucial to decrease mortality rate. In case of Diabetes, clinicians and experts are finding challenging the timely diagnosis and analyzing the chances of developing underlying diseases. In this paper, Louvain Mani-Hierarchical Fold Learning healthcare analytics, a hybrid deep learning technique is proposed for medical diagnostics and is tested and validated using real-time dataset of 104 instances of patients with dengue fever made available by Holy Family Hospital, Pakistan and 810 instances found for infectious diseases including prognosis of; Covid-19, SARS, ARDS, Pneumocystis, Streptococcus, Chlamydophila, Klebsiella, Legionella, Lipoid, etc. on GitHub. Louvain Mani-Hierarchical Fold Learning healthcare analytics showed maximum 0.952 correlations between two clusters with Spearman when applied on 240 instances extracted from comorbidities diagnostic data model derived from 15696 endocrine records of multiple visits of 100 patients identified by a unique ID. Accuracy for induced rules is evaluated by Laplace (Fig. 8) as 0.727, 0.701 and 0.203 for 41, 18 and 24 rules, respectively. Endocrine diagnostic data is made available by Shifa International Hospital, Islamabad, Pakistan. Our results show that in future this algorithm may be tested for diagnostics on healthcare big data.

Genetic analysis of failed male puberty using whole exome sequencing.

OBJECTIVES: Although at least 598 genes are involved in the development of the hypothalamo-pituitary-testicular (HPT) axis, mutations in only 75 genes have so far been shown to cause delayed puberty. METHODS: Six male patients with failed puberty, manifested as absence of pubertal changes by 18 years of age, underwent whole exome sequencing of genomic DNA with subsequent bioinformatics analysis and confirmation of selected variants by Sanger sequencing. Genes having plausibly pathogenic non-synonymous variants were characterized as group A (previously reported to cause delayed puberty), group B (expressed in the HPT-axis but no mutations therein were reported to cause delayed puberty) or group C (not reported previously to be connected with HPT-axis). RESULTS: We identified variants in genes involved in GnRH neuron differentiation (2 in group A, 1 in group C), GnRH neuron migration (2 each in groups A and C), development of GnRH neural connections with supra-hypothalamic and hypothalamic neurons (2 each in groups A and C), neuron homeostasis (1 in group C), molecules regulating GnRH neuron activity (2 each in groups B and C), receptors/proteins expressed on GnRH neurons (1 in group B), signaling molecules (3 in group C), GnRH synthesis (1 in group B), gonadotropins production and release (1 each in groups A, B, and C) and action of the steroid hormone (1 in group A). CONCLUSIONS: Non-synonymous variants were identified in 16 genes of the HPT-axis, which comprised 4 in group A that contains genes previously reported to cause delayed puberty, 4 in group B that are expressed along HPT-axis but no mutations therein were reported previously to cause delayed puberty and 8 in group C that contains novel candidate genes, suggesting wider genetic causes of failed male puberty.

Weight and Body Mass Index for Predicting Thyroxine Dose in Primary Hypothyroidism.

Background The treatment of primary hypothyroidism with thyroxine is weight-based or body mass index (BMI)-based. However, significant variation in the dose and the consequent delay in achieving euthyroid state is observed along the spectrum of patient body weights. Objectives To determine the weight and BMI-based dosing of thyroxine in primary hypothyroidism to achieve euthyroidism. Material and methods It was a retrospective review of the patient records conducted in the department of endocrinology, Shifa International Hospital, Islamabad, from July 1, 2014, to June 30, 2019 (five-year period). Patients with clinical and biochemical hypothyroidism were enrolled and initiated on thyroxine replacement to achieve euthyroid status. A total of 504 patients were included in the study. Results The mean age was 44.5 ±13.6 standard deviation. Females were 83.5%. The mean dose of thyroxine to achieve euthyroid status was 107.7 ± 39.3 mean standard deviation mcg/day, i.e. 1.4 (0.5) mcg/kg/day. Euthyroid status was achieved in 264 (52.4%) of patients at three months. The mean TSH level after treatment was 2.09 (1.2) mU/L. The linear regression model showed that BMI and weight are independent predictors of the required thyroxine dose (R and Rsquare values are .274 and 0.075 for BMI and .319 and .102 for weight, respectively (P-value <.0001). There was no impact of age, gender, height, and duration of disease on achieving euthyroid at six months after treatment (P values: .85, .394, .827, and .105, respectively). Conclusion The optimum dose in primary hyperthyroidism can be determined with body weight and BMI-based calculations.

Efficacy and Safety of Dulaglutide in Type 2 Diabetes Patients in Endocrinology Clinics of Islamabad, Pakistan.

Objective: Our objective was to ascertain the efficacy and safety of once weekly Dulaglutide among patients with Type 2 diabetes of Pakistani origin. Methods: This prospective cohort study was conducted at the Endocrinology Clinics of Shifa International Hospital, Islamabad and Umar Diabetes and Foot Care Centre, Islamabad, Pakistan during the period from July 2020 to December 2020. Dulaglutide at the dose of 1.5 mg once weekly was initiated in patients with BMI >28 and suboptimal glucose control in the background of Type 2 Diabetes who were also taking one or more of oral anti-diabetic and/or insulin therapy. Results: Mean age of patient cohort (n = 148) was 49.51 years (SD +/- 12.15) with 53.5% (n = 85) having type 2 diabetes for a duration of over 10 years. Mean weight was 93.2 kg at baseline with end of study mean weight being 90.7 kg. Mean HbA1c at baseline was 9.2%, which improved to 8.05% at the end of study. The main side-effects were nausea in 32%, vomiting in 8%, and diarrhea in 7% with 19% discontinuation rate due to cost and side-effects. Conclusion: Dulaglutide as a therapy demonstrated favorable HbA1c and weight reduction in obese type 2 diabetes patients of Pakistani origin.

The Outcomes of Dapagliflozin Use in Real-Life Clinical Settings in Endocrinology Clinics of Islamabad, Pakistan.

Introduction Dapagliflozin is a member of a novel class of drugs (sodium-glucose cotransporter-2 inhibitors) used to treat type 2 diabetes mellitus and licensed in Pakistan in 2017. This retrospective observational study evaluated the effects of dapagliflozin on glycated hemoglobin (HbA1c) concentrations in patients treated at endocrinology clinics in Islamabad, Pakistan. The secondary objectives included assessing the effects of dapagliflozin on weight reduction and blood pressure control and to determining its safety. Methodology Patients with type 2 diabetes who were treated with dapagliflozin were identified by screening the electronic medical records at tertiary care hospitals in Islamabad. Data were collected at the first visit and at follow-up. Categorical variables were recorded as frequencies and percentages and compared by McNemar's tests, and continuous variables were recorded as means and standard deviations and compared by paired sample t-tests. Results Mean HbA1C concentration was significantly lower at follow-up than at the first visit (7.57%±0.98% vs. 9.07%±2.07%, respectively; p<0.001). Bodyweight (85.09±15.92 kg vs. 87.07±16.11 kg, respectively; p<0.001) and diastolic blood pressure (80.34±7.12 mmHg vs. 82.34±9.61 mmHg, respectively; p<0.001) were also significantly lower at follow-up than at the first visit, whereas systolic pressure showed a marginally significant reduction (123.5±16.57 mmHg vs. 126.83±19.97 mmHg, p=0.048). Conclusion This first observational study of patients in Pakistan treated with dapagliflozin found that HbA1c concentration, weight, and blood pressure were reduced after initiation of dapagliflozin treatment.

Effectiveness, Safety, and Patient Satisfaction of Liraglutide in Type 2 Diabetic Patients.

Background and Objectives Liraglutide, an analog of human glucagon-like peptide 1 (GLP-1), has been approved for the treatment of type 2 diabetes mellitus in Pakistan since 2016. It is a GLP-1 receptor agonist that has shown promising results in terms of not only glycemic control but also weight loss. Our study aimed to provide evidence regarding the safety and effectiveness of liraglutide in Pakistan and to look at the adherence rate and treatment satisfaction of patients using liraglutide. Methods This is an observational retrospective study that recruited patients who were treated with liraglutide. Data were collected at the first visit and follow-up. Morisky Green Levine Adherence Scale and Treatment Satisfaction Questionnaire for Medication (TSQM-9) were used for the determination of adherence and satisfaction with the treatment. Results A total of 70 patients were recruited in the study, The mean difference in weight, body mass index, glycated hemoglobin (HbA1C), systolic blood pressure, and diastolic blood pressure from baseline to follow-up was -5.36 kg, -2.14 kg/m2, -1.76%, -12.38 mmHg, and 5.55 mmHg, respectively. Nausea was the main side effect reported. TSQM-9 scores were compared from baseline, and it was found that patients are satisfied with the treatment and its effectiveness. Conclusions Our study has demonstrated the effectiveness of liraglutide as a monotherapy or combination therapy in the Pakistani population. Liraglutide led to reduction in HbA1C and weight. This is associated with high treatment satisfaction rate and adherence rate. Thus, liraglutide remains an effective though expensive treatment option in a country like Pakistan.

Remission of Grave's disease after oral anti-thyroid drug treatment.

OBJECTIVE: To evaluate remission rate of anti-thyroid drug treatment in patients with Grave's disease, and to study the factors associated with remission. STUDY DESIGN: A cross sectional study. PLACE AND DURATION OF STUDY: The Endocrine Department of the Aga Khan University Hospital, Karachi from 1999 to 2000. METHODOLOGY: Seventy four patients of Grave's disease were recruited who were prescribed medical treatment. Grave's disease was diagnosed in the presence of clinical and biochemical hyperthyroidism along with anti-microsomal (AMA) and anti-thyroglobulin antibodies (ATA) and thyroid scan. These patients were prescribed oral anti-thyroid drugs using titration regime and followed at 3, 6, 12 and 18 months. Patients were categorized into two groups: "remission group" and "treatment failure group" and results were compared using a chi-square test, t-test and logistic regression model with significance at p < 0.05. RESULTS: A majority of the patients were females (62.6%, n=46). During the follow-up period of 18 months, 41.9% patients went into remission. Univariate analysis showed that the initial free T4 level was significantly different (p < 0.05) in patients in remission and treatment failure groups. Multivariate analysis showed only initial free T4 level was a significant predictor of outcome. Positive AMA patients (n=27) had higher treatment failure (odds ratio: 2.55: 95%, CI 0.69 - 9:31), although the difference was not statistically significant (p = 0.13). CONCLUSION: Remission rates with oral anti-thyroid agents is markedly high. Patients should be offered alternate treatment options to those who do not enter remission during a period of 12-18 months of treatment, those who develop relapse, and those who have aggressive disease on initial presentation.

Etiology, functional status and short term outcome of patients with pituitary lesions. An experience from a developing country.

OBJECTIVE: To describe the etiology, functional status and short term outcome of patients with pituitary lesions (PL). METHODS: Brain or pituitary MRI reports of 3753 patients were analyzed for PL over the period of 2000 to 2007, done at the Aga Khan University Hospital (AKUH), Karachi, Pakistan. MRIs with reported PL and all those ordered by Endocrinologists with or without pituitary abnormalities, were included in the analysis. This made a total of 338 (9%) MRI reports. PL were defined as pituitary tumors, cysts, haemorrhage, hypoplasia; and empty sella. Patients with these PL, were analyzed for symptoms, hormonal profile and short term outcome in the hospital retrospectively. RESULTS: In the analysis of 338 MRI reports, 23% had normal pituitary gland on MRI examination. Hypogonadotrophic hypogonadism was the commonest (38.5%) endocrine abnormality seen with normal pituitary MRI, followed by hypopituitarism (5.1%). Most common PL identified were macroadenoma (38.7%), empty sella (16.5%) and microadenoma (12.7%). Patients with macroadenoma had 58% of non-functional tumours while 19.1% had hypopituitrism, 17.6% had acromegaly and 17.5% had prolactinoma. Majority of these lesions were causing headache and visual symptoms (42.7%) and were treated with surgery (75.5%). Patients with microadenoma included 39.5% prolactinomas, 18.6% cushing disease, 14% acromegaly, 4.7% hypogonadotrophic hypogonadism and 2.3% hypopituitrism. Majority of these lesions were treated with drugs and 37.3% were treated with surgery. In empty sella patients, 32% patients had endocrine abnormalities among which 21.4% had hypopituitrism, 2% had hypogonadotrophic hypogonadism, and only 6% patients had normal endocrine workup. A significant number of patients (62.5%) never had endocrine hormonal checkup. CONCLUSION: Although PL are less common entities (9% in 3,753 reports) but they are associated with significant endocrinal abnormalities and need prompt treatment. Empty sella, which is not considered as a distinct abnormality, is also associated with significant endocrine deficiencies.

Diabetes Prevalence Survey of Pakistan (DPS-PAK): prevalence of type 2 diabetes mellitus and prediabetes using HbA1c: a population-based survey from Pakistan.

OBJECTIVES: We conducted a Pakistan-wide community-based survey on the prevalence of type 2 diabetes using glycated haemoglobin (HbA1c) as the screening test. The aim was to estimate diabetes prevalence across different demographic groups as well as all regions of Pakistan. DESIGN, SETTINGS AND PARTICIPANTS: Multistaged stratified cluster sampling was used for the representative selection of people aged ≥20 years, residing in 378 sampled clusters of 16 randomly selected districts, in this cross-sectional study. Eligible participants had blood drawn for HbA1c analyses at field clinics near to their homes. The oral glucose tolerance test (OGTT) was conducted on a subsample of the participants. Overall and stratified prevalence of type 2 diabetes and its association with risk factors were estimated using logistic regression models. MAIN OUTCOME MEASURES: Prevalence of prediabetes and type 2 diabetes. RESULTS: Of 18 856 eligible participants the prevalence of prediabetes was 10.91% (95% CI 10.46 to 11.36, n=2057) and type 2 diabetes was 16.98% (95% CI 16.44 to 17.51, n=3201). Overall, the mean HbA1c level was 5.62% (SD 1.96), and among newly diagnosed was 8.56% (SD 2.08). The prevalence was highest in age 51-60 years (26.03%, p<0.001), no formal education (17.66%, p<0.001), class III obese (35.09%, p<0.001), family history (31.29%, p<0.001) and female (17.80%, p=0.009). On multivariate analysis, there was a significant association between type 2 diabetes and older age, increase in body mass index and central obesity, positive family history, and having hypertension and an inverse relation with education as a categorical variable. On a subsample (n=1027), summary statistics for diagnosis of diabetes on HbA1c showed a sensitivity of 84.7%, specificity of 87.2% and area under the receiver operating characteristic curve 0.86, compared with OGTT. CONCLUSIONS: The prevalence of type 2 diabetes and prediabetes is much higher than previously thought in Pakistan. Comprehensive strategies need to be developed to incorporate screening, prevention and treatment of type 2 diabetes at a community level.

Outcome of cardiopulmonary resuscitation - predictors of survival.

OBJECTIVE: To assess the outcomes of patients undergoing cardiopulmonary resuscitation (CPR). DESIGN: A cross-sectional study. PLACE AND DURATION OF STUDY: Shifa International Hospital, Islamabad from January 2005 to December 2005. PATIENTS AND METHODS: Data were collected retrospectively of all adult patients who underwent CPR. Clinical outcomes of interest were survival at the end of CPR and survival at discharge from hospital. Factors associated with survival were evaluated using logistic regression analysis. RESULTS: Of the 159 patients included, 55 (35%) were alive at the end of CPR and 17 (11%) were discharged alive from the hospital. At the end of CPR, univariate logistic regression analysis found the following factors associated with survival: cardiac arrest within hospital as compared to outside the hospital (odds ratio = 2.8, 95% CI = 1.27-6.20, p-value = 0.01), both cardiac and pulmonary arrest as compared to either cardiac or pulmonary arrest (odds ratio = 0.37, 95%CI = 0.19- 0.73, p-value = 0.004), asystole as cardiac rhythm at presentation (odds ratio = 0.47, 95%CI = 0.24-0.93, p-value = 0.03), and total atropine dose given during CPR (odds ratio = 0.78, 95%CI = 0.62-0.97, p-value = 0.02). In multivariate logistic regression, cardiac arrest within hospital (odds ratio = 2.52, 95%CI = 1.06-5.99, p-value = 0.04) and both cardiac and pulmonary arrest as compared to cardiac or pulmonary arrest (odds ratio = 0.44, 95%CI = 0.21-0.91, p-value = 0.03) were associated with survival at the end of CPR. At the time of discharge from hospital, univariate logistic regression analysis found following factors that were associated with survival: cardiac arrest within hospital (odds ratio = 8.4, 95%CI = 1.09-65.64, p-value = 0.04), duration of CPR (odds ratio = 0.91, 95%CI = 0.85-0.96, p-value = 0.001), and total atropine does given during CPR (odds ratio = 0.68, 95%CI = 0.47-0.99, p-value = 0.05). In multivariate logistic regression analysis cardiac arrest within hospital (odds ratio = 8.69, 95%CI = 1.01-74.6, p-value = 0.05) and duration of CPR (odds ratio = 0.92, 95%CI = 0.87-0.98, p-value = 0.01) were associated with survival at discharge from hospital. CONCLUSION: In-hospital cardiopulmonary arrest was associated with better clinical outcomes as compared to outside hospital arrest. Public education is needed to improve clinical outcomes in patients who need CPR outside hospital.

Empysematous gastritis--a case report with literature review.

Emphysematous gastritis is a condition characterized by gas within the wall of the stomach and associated, systemic toxicity. We are reporting to our knowledge the first case of emphysematous gastritis in a 76 year old female from Islamabad, Pakistan. She was admitted with five day history of upper abdominal discomfort and vomiting. Diagnosis of emphysematous gastritis was made on CT scan. She was treated successfully with conservative management including IV antibiotics and few sessions of dialysis, and was discharged home within two weeks.

Fasting with diabetes: a prospective observational study.

OBJECTIVES: To determine the proportion of diabetic patients who develop adverse glycaemic events when fasting regularly. DESIGN: Prospective observational study conducted at a tertiary care hospital in South Asia. Five hundred and twenty-three patients were assessed for eligibility, and 150 were included in the final analysis. Diabetic patients over 18 years of age who were willing to fast regularly and make a chart of their daily blood sugar levels were included in the study. The main outcome measures were hypoglycaemic and hyperglycaemic events. Frequencies and percentages were calculated for quantitative variables, while mean±SD were documented for qualitative variables. Relative risk was calculated as a measure of association. RESULTS: Of a total of 150 individuals, 10% experienced hypoglycaemia, while 3.3% reported hyperglycaemic episodes. Only 8.7% of the participants discontinued one or more fasts; however, none of them required hospitalisation. There is a negative association between a visit to a physician by diabetic patients before they begin to fast regularly and the risk of developing hypoglycaemia (relative risk 0.73). CONCLUSIONS: Many diabetic patients who fast regularly are at high risk of adverse glycaemic events. Most diabetics do not consult their physicians before fasting to adjust medications and lifestyle. Various strategies should be planned and implemented for the awareness and education of such patients to avoid adverse glycaemic events and subsequent complications.

Comparison of store and forward method of teledermatology with face-to-face consultation.

BACKGROUND: To compare the accuracy of store and forward method of teledermatology with the traditional face-to-face consultation. METHODS: The comparison was done between Institute of Dermatology King Edward Medical College Lahore that served as teledermatology center and Dermatology Department of Pakistan Institute of Medical Sciences Islamabad from where patients were selected. Telmedpak provided the technical support. Thirty three patients were selected from outpatient department of PIMS and images were taken using a digital camera. Images were stored in computer and were sent to Institute of Dermatology via e-mail for Teleconsultation along with a short history and examination findings. Diagnosis of consultant after face-to-face consultation was then compared with the image based diagnosis that is after teleconsultation. RESULTS: In 81% of the cases the diagnosis on face-to-face consultation was same (p < 0.05) while in 18% of the cases the two diagnoses differed. In 9% (n = 3) of the cases, image resolution was not good but out of these three, diagnosis was same in two and differed in one case. CONCLUSION: This study concludes that store and forward method of teledermatology is reliable and can provide a means of increasing access to dermatological care in rural and under-served areas.

Patterns of pancytopenia patients in a general medical ward and a proposed diagnostic approach.

BACKGROUND: There has been little systematic study on the clinical spectrum of pancytopenia. This study was done to describe the etiology, presentation and outcome of patients with pancytopenia presenting in a general medical ward. METHODS: Hundred patients with pancytopenia were included in the study from October 2001 to October 2002. Patients on cancer chemotherapy were excluded. Blood counts, bone marrow examinations and trephine biopsies were performed according to standard methods. RESULTS: In all cases, megaloblastic anemia constituted the largest group (n = 39), and also seen in conjunction with hemolytic anemia and septicemia. Hypersplenism secondary to portal hypertension (cirrhosis) was the second most common diagnosis (n = 19). Aplastic anemia, septicemia and myelodysplasia were other common causes. Two patients were the suspected cases of viral hemorrhagic fever. Thirteen (13%) patients expired. Absolute neutrophil count (ANC) less than 500/microliter was seen in 14 (14%) patients, among which 6 (15.3%) had megaloblastic anemia, 3 (37.5%) had aplastic anemia, and 2 (40%) had myelodysplasia. Eleven patients with platelet counts < or = 10 x 10(9)/L, 6 (54.5%) presented with bleeding; and 2 of these 8 had aplastic anemia and 1 patient with megaloblastic anemia. MCV values > 100 fL and > 110 fL were more frequent in patients with megaloblastic anemia with most prominent anisopoikilocytosis, microcytosis and fragmented RBCs. Macrocytosis was noted in 35 (89.7%) patients with megaloblastic anemia and 12 (63.1%) with hypersplenism, 4 (50%) with aplastic anemia. Hypersegmented neutrophils were noted in the blood films of 36 (92.3%) patients with megaloblastic anemia. CONCLUSION: Megaloblastic anemia, hypersplenism and aplastic anemia are the common causes of pancytopenia in our study.

Adjuvant Hormonal Therapy in Postmenopausal Women with Breast Cancer: Physician's Choices.

The choice of adjuvant hormonal therapy in postmenopausal women with hormone receptor positive breast cancer has remained a matter of controversy and debate. The variety of agents is available, with each claiming to be superior. This clinical survey was undertaken to get an impression of the physician's first choice of therapy in an attempt to find out what questions still need to be answered in the making of "standard of care." A web-based clinical survey was sent to the cancer physicians around the world, and 182 physicians responded to the survey. Most were medical oncologists in a tertiary care hospital. 36.3% preferred Anastrozole, 35.2% Tamoxifen, and 22.2% Letrozole as their first choice. Data support (67.8%) and safety concerns (30%) were given as the main reasons for the choice, 63.7% switched their therapy, and 24% had to switch because of side effects. 73.6% used 5 years of adjuvant hormonal therapy, 6.6% for 7 years, and 4.4% for 10 years. 61.5% follow their patients 3 times monthly, and 73.2% used laboratory and radiological assessment at each followup. Conclusion. Physicians show disagreement over the choice and duration of hormonal therapy in this patient population. Clinical trials leading to firm recommendations to set standards from which patients benefit the most are needed.

Diabetic emergencies including hypoglycemia during Ramadan.

Majority of physicians are of the opinion that Ramadan fasting is acceptable for well-balanced type 2 patients conscious of their disease and compliant with their diet and drug intake. Fasting during Ramadan for patients with diabetes carries a risk of an assortment of complications. Islamic rules allow patients not to fast. However, if patient with diabetes wish to fast, it is necessary to advice them to undertake regular monitoring of blood glucose levels several times a day, to reduce the risk of hypoglycemia during day time fasting or hyperglycemia during the night. Patient with type 1 diabetes who fast during Ramadan may be better managed with fast-acting insulin. They should have basic knowledge of carbohydrate metabolism, the standard principles of diabetes care, and pharmacology of various antidiabetic drugs. This Consensus Statement describes the management of the various diabetic emergencies that may occur during Ramadan.