Consensus Guidelines for Influenza Vaccination in Patients with Diabetes.

Influenza is a prevalent health issue encountered in daily practice. Patients with diabetes mellitus face a higher risk of infections, including influenza, owing to the compromised immune system associated with diabetes. This susceptibility arises from the potential of diabetes mellitus to weaken the immune system. Moreover, elevated blood glucose levels can create a conducive environment for the growth of bacteria and viruses. This consensus is formulated by a multidisciplinary team to serve as practical guidance for the administration of influenza vaccinations to patients with diabetes mellitus in daily practice.

The role of high fat diet on serum uric acid level among healthy male first degree relatives of type 2 diabetes mellitus.

First-degree relatives (FDR) of type 2 diabetes mellitus have increased risk of developing insulin resistance-related disorders including hyperuricemia. We investigated metabolic profile and serum uric acid (SUA) metabolism in response to high-fat diet among healthy male FDR in comparison to those without family history of diabetes. A total of 30 FDR and 30 non-FDR subjects completed a 5-days-hypercaloric diet with fat added to regular daily intake. Despite similar insulin response, FDR displayed different changes in SUA compared to non-FDR subjects (0.26 ± 0.83 mg/dL vs - 0.21 ± 0.78 mg/dL, p = 0.028). In subgroup analyses stratified by body mass index and waist circumference, significant different SUA changes between FDR and non-FDR subjects were only found in obese (0.48 ± 0.87 mg/dL vs - 0.70 ± 0.71 mg/dL, p = 0.001) and centrally obese (0.59 ± 0.83 mg/dL vs - 0.55 ± 0.82 mg/dL, p = 0.011) subgroups. In multivariate analysis, visceral adiposity seemed mediating the different response in SUA metabolism between FDR and non-FDR subjects induced by short-term obesogenic diet.

Differential effect of ramadan fasting on intercellular adhesion molecule-1 (ICAM-1) in diabetes mellitus and non-diabetes mellitus patients.

Background: The month of Ramadan is a holy month for Muslims. During this month, Muslims do not eat, drink, or smoke from sunrise to sunset. Patients with type 2 diabetes mellitus (T2DM) will also fast from dawn to dusk, creating a unique opportunity to study the effects of dietary changes during fasting period. One of the interesting results of Ramadan fasting is its effect on endothelial dysfunction, measured using Intercellular Adhesion Molecule-1 (ICAM-1) as a biological marker of endothelial function. Aim: To determine the changes ICAM-1 levels in T2DM and non-DM patients during Ramadan fasting. Methods: A retrospective cohort study was performed on 26 T2DM patients and 21 non-DM, age-matched patients (aged 19-60 years). Measurement of metabolic parameters (systolic and diastolic blood pressure, total calorie intake, and intensity of physical activity), anthropometry (body weight, body mass index (BMI) and abdominal circumference), total dietary intake, and laboratory analysis (blood glucose fasting, HbA1c, lipid profile, ICAM-1) were done at 4 weeks before (T0) and 14 days after Ramadan fasting (T1). Result: The median ICAM-1 level in T2DM patients at T0 was 340.9 (193-505) ng/mL and at T1 was 312.3 (158-581) ng/mL, while the ICAM-1 level in non-DM patients at T0 was 482 (305-653) and at T1 was 398.4 (202-526) ng/mL. There was no significant difference of ICAM-1 level between study groups at both T0 and T1 (p > 0.05). Both T2DM and non-DM patients had lower ICAM-1 level following Ramadan fasting. However, only non-DM patients had significantly lower post Ramadan ICAM-1 (p = 0.008). Conclusion: There was a significant decrease in ICAM-1 level in both T2DM and non-DM patients after Ramadan fasting.

Cultivating patient-centered care competence through a telemedicine-based course: An explorative study of undergraduate medical students' self-reflective writing.

Background: The COVID-19 pandemic has encouraged adaptations of learning methods in clinical clerkship. There have been limited reports on the merits of involving medical students in telemedicine. This study, therefore, aims to investigate students' reflection on what they learned and identify the challenges and benefits of doctor-patient interaction through their experience in a telemedicine-based course. Methods: A 4 week telemedicine-based course for medical students to participate in telemonitoring of COVID-19 patients undergoing self-isolation was conducted. This is a qualitative study using an interpretive phenomenology design to investigate students' self-reflection on their experiences in monitoring COVID-19 patients. Students were asked to reflect on their experience upon completion of the course through 750-1,000 words essays. A thematic analysis which considers units of meaning based on students' experiences was completed. Results: Our study identified four main themes gathered from students' experiences related to the telemedicine-based course: communication and education, professionalism and professional identity formation, system-based practice, and patient-centered care. Conclusion: The course was part of an integrative effort involving multiple parties to tackle the burden on the nation's healthcare system during the pandemic. Telemedicine is part of future medical practice which supports the medical curriculum adaptability along with attempts to develop future-proof medical doctors through various clinical learning experiences.

Autologous intraarterial pancreatic bone-marrow mononuclear cells infusion in T2D patients: Changes on beta-cells function, insulin resistance, and inflammatory marker.

BACKGROUND: Type 2 diabetes (T2D) is a progressive disease. Many drugs currently being used for the management of T2D have minimal effect on pancreatic beta cells regeneration. Cell-based therapies might provide potential benefits in this aspect. METHODS: A pilot study in five T2D patients with 12 months follow-up was performed to evaluate the effect of autologous bone marrow mononuclear stem cells (BM-MNCs) infusion into pancreatic arteries on the insulin requirement, beta-cell function, insulin resistance, and systemic inflammatory marker (CRP). RESULTS: The primary endpoint, a 50 % reduction of total insulin doses from baseline, was not achieved in this study. However, a trend of increasing fasting C-peptide (p = 0.07) and C-peptide 60' (p = 0.07) and 90' (p = 0.07) after a mixed-meal tolerance test was observed 12 months post-infusion compared to baseline levels. A similar result was observed for the homeostatic model assessment of beta cell function (HOMA1-B), an index for beta cell function. No improvement was observed for insulin resistance measured by homeostasis model assessment of insulin resistance (HOMA1-IR) and systemic inflammatory parameter. CONCLUSION: Intraarterial pancreatic autologous BM-MNCs infusion might potentially improve beta cell function in T2D patients, although further study is needed to confirm this finding.

A COVID-19 self-isolation monitoring module for FMUI undergraduate medical students: Linking learning and service needs during the pandemic surge in Indonesia.

To ensure that students continued receiving adequate yet safe clinical exposure during the COVID-19 pandemic, the Faculty of Medicine at Universitas Indonesia (FMUI) created the Module of COVID-19 Self-Isolation Monitoring which aims to equip students with the knowledge and skill to monitor confirmed and close contact cases of COVID-19. Module development, divided into four phases: preparation, orientation, implementation, and evaluation phase, started as soon as the delta wave of COVID-19 cases forced medical students to halt their offline clinical rotations. A quantitative secondary data were obtained from student and patient satisfaction questionnaires and on students' performance and reflection. We analyzed the distribution of module evaluation, the student's discussion score during the module, the students' interest in participating as Covid-19 volunteers before and after the module's deployment, and the correlation between learning outcomes and satisfaction. A total of 372 patients were monitored by 208 students during the 4-week module. The response rates were above 80%, with the majority agreeing that students found this module well-organized and fulfilled their expectations. There was a significant increase in discussion scores from weeks 1 to 4, a significant difference in the proportion of students interested in COVID-19 volunteering before and after the module completion as well as a significant low correlation between the patient's monitoring score sheet and the reflection essay towards the patient's satisfaction. We should still improve tutors' time management, tutors' provision of triggering questions for critical thinking skills, and tutors' feedback for students. The module met patient expectations and is expected to assist tutors in providing feedback and examples of doctor-patient communication, thus accelerating students' competence in patient interaction. Further evaluation is needed regarding knowledge transfer, the impact on community health, and the faculty development program, especially regarding how tutors fulfill their roles as medical educators.

The efficacy of vitamin B12 supplementation for treating vitamin B12 deficiency and peripheral neuropathy in metformin-treated type 2 diabetes mellitus patients: A systematic review.

BACKGROUND AND AIMS: Metformin-treated type 2 diabetes mellitus (T2DM) patients are at higher risk of vitamin B12 deficiency and more severe neuropathy symptoms. There is still no guideline suggesting vitamin B12 supplementation for this population. This study aimed to analyze the efficacy of vitamin B12 supplementation in this population. METHOD: Studies reporting the efficacy of vitamin B12 supplementation in metformin-treated T2DM patients were systematically searched in PubMed, Cochrane, EBSCOHost, and Scopus following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Additional relevant studies were searched manually through citations. Study quality and risk of bias were assessed using suitable tools. RESULTS: Seven clinical trials with a total of 506 participants were included. Using the Cochrane's Risk of Bias 2 tools for clinical trials, 4 studies were assessed to have high risk of bias and 3 studies had low risk of bias. There were 5 studies that measured changes in serum vitamin B12 level, all of which reported a statistically significant increase after supplementation. Significant reductions in homocysteine after supplementation were found in 2 studies. Its effect on neuropathy symptoms was still unclear, with 2 studies reporting a significant improvement and 1 study reporting no significant effect. CONCLUSIONS: The results of this systematic review support the implementation of vitamin B12 supplementation for metformin-treated T2DM to prevent or treat vitamin B12 deficiency and neuropathy. More high-quality clinical studies are required to generate quantitative analysis and to encourage supplementation in available guidelines.

The Effect of Statin Therapy on Mortality in Adult Patients with Liver Cirrhosis: An Evidence-Based Case Report.

BACKGROUND: Liver cirrhosis causes over one million deaths annually worldwide, but its prognosis varies depending on the presence of complications and decompensating events. Reduction of portal pressure is associated with a reduced risk of mortality in cirrhotic patients. Statin therapy has successfully reduced portal pressure in previous studies, but its effects on overall mortality are unclear. This report aims to determine whether statin therapy significantly affects mortality in patients with liver cirrhosis. METHODS: A comprehensive literature search was conducted using five electronic databases: PubMed, Scopus, Embase, Ovid MEDLINE, and Web of Science. Meta-analyses, randomized controlled trials (RCTs), and cohort studies were selected based on pre-set inclusion and exclusion criteria. The quality of selected studies was evaluated using critical appraisal tools developed by the Center for Evidence-Based Medicine. RESULTS: One meta-analysis, one RCT, and one retrospective cohort study were included in this report. The meta-analysis and cohort study were of good quality and reported significantly reduced mortality with statin therapy in cirrhosis patients. However, the RCT had poor validity and did not report a statistically significant difference in mortality between the intervention and control groups. The survival benefits of statins may be limited to Child-Pugh A and B patients only, but this requires confirmation in a larger population of Child-Pugh C patients. CONCLUSION: Statins potentially reduce mortality in patients with liver cirrhosis, but more evidence is required before they can be widely recommended in clinical practice for this indication.

Diagnostic accuracy of palpation versus ultrasound-guided fine needle aspiration biopsy for diagnosis of malignancy in thyroid nodules: a systematic review and meta-analysis.

Thyroid nodule is a common health problem in endocrinology. Thyroid fine-needle aspiration biopsy (FNAB) cytology performed by palpation guided FNAB (PGFNAB) and ultrasound-guided FNAB (USGFNAB) are the preferred examinations for the diagnosis of thyroid cancer and part of the integration of the current thyroid nodule assessment. Although studies have shown USGFNAB to be more accurate than PGFNAB, inconsistencies from several studies and clinical guidelines still exist.The purpose of this study is to compare the diagnostic accuracy of Palpation versus Ultrasound-Guided Fine Needle Aspiration Biopsy in diagnosing malignancy of thyroid nodules.The systematic review and meta-analysis were prepared based on the PRISMA standards. Literature searches were carried out on three online databases (Pubmed/MEDLINE, Embase, and Proquest) and grey literatures. Data extraction was carried out manually from various studies that met the eligibility, followed by analysis to obtain pooled data on sensitivity, specificity, Diagnostic Odds Ratio (DOR) and Area Under Curve (AUC), and the comparison of the two methods.Total of 2517 articles were obtained, with 11 studies were included in this systematic review. The total sample was 2382, including 1128 subjects using PGFNAB and 1254 subjects using USGFNAB. The risk of bias was assessed using QUADAS-2 with mild-moderate results. The results of sensitivity, specificity, AUC and DOR in diagnosing thyroid nodules using PGFNAB were 76% (95% CI, 49-89%), 77% (95% CI, 56-95%), 0.827 and 11.6 (95% CI, 6-21) respectively. The results of sensitivity, specificity, AUC and DOR in diagnosing thyroid nodules using USGFNAB were 90% (95% CI, 81-95%), 80% (95% CI, 66-89%), 0.92 and 40 (95% CI, 23-69), respectively the results of the comparison test between PGFNAB and USGFNAB; Tsens USGFNAB of 0.99 (p = 0.023), AUC difference test of 0.093 (p = 0.000023).The diagnostic accuracy of USGFNAB is higher than PGFNAB in diagnosing malignancy of thyroid nodules. If it is accessible, the author recommends using USGFNAB as a diagnostic tool for thyroid nodules.

Characteristics of Diabetic Foot Ulcer Patients Pre- and During COVID-19 Pandemic: Lessons Learnt From a National Referral Hospital in Indonesia.

BACKGROUND: Diabetic foot ulcer (DFU) is one of the most terrifying diabetic complications for patients, due to the high mortality rate and risk for amputation. During the COVID-19 pandemic, many diabetic patients limited their visits to the hospital, resulting in delays for treatment especially in emergency cases. OBJECTIVE: This study aimed to compare the characteristics of patients with DFU pre- and during COVID-19 pandemic period. Methods: This study was a retrospective cohort study using foot registry data. We compared our patients' characteristics pre-COVID-19 pandemic period (1 March 2019-28 February 2020) and during COVID-19 pandemic period (1 March 2020-28 February 2021). RESULTS: Cohorts of 84 and 71 patients with DFU pre- and during COVID-19 pandemic period, respectively, were included in this study. High infection grade (66.7% vs 83.1%, P = .032), osteomyelitis event (72.6% vs 87.3%, P = .04), leukocyte count (15 565.0/µL vs 20 280.0/µL, P = .002), neutrophil-to-lymphocyte ratio (7.7 vs 12.1, P = .008), waiting time-to-surgery (39.0 h vs 78.5 h, P = .034), and number of major amputation (20.2% vs 39.4%, P = .014) were significantly higher during the COVID-19 pandemic period. CONCLUSION: During the COVID-19 pandemic, patients with DFU had more severe infection, higher proportion of osteomyelitis, longer waiting time for getting surgical intervention, and higher incidence of major amputation.

Association between Statin Use and Poor Outcomes in COVID-19 Patients with Diabetes Mellitus: A Systematic Review.

BACKGROUND AND AIMS: Diabetes mellitus, cardiovascular diseases, obesity, and dyslipidaemia are considered risk factors for more severe forms of COVID-19 infection. Statins have been widely used in such patients to prevent the occurrence of cardiovascular events and the associated mortality. However, statin use has been suggested to promote a more severe form of infection. This review aims to investigate the association between statin use and poor outcomes in COVID-19 patients with diabetes. METHODS: Literature search was performed in PubMed, CENTRAL, Scopus, and pre-print databases (MedRxiv and BioRxiv), and studies published up to March 6th, 2021 have been reviewed. Selected studies were then assessed for risk of bias with the Newcastle Ottawa Scale. RESULT: Four studies were included in the final analysis; all were retrospective studies. Two studies reported a decreased risk of mortality with statin use, while one study reported opposite findings. The other one did not find a significant association between statin use and poor COVID-19 outcomes. CONCLUSION: Available data suggest that statins may be safely administered to diabetic COVID-19 patients as the majority of evidence signifies statins to confer benefits and improve clinical outcomes in COVID-19 patients.

Does Insulin Use Worsen the Prognosis of COVID-19 Patients with Type 2 Diabetes Mellitus? A Current Update.

BACKGROUND: Insulin has recently received special attention concerning its use in COVID-19 patients. Although controversial, insulin can be able to worsen the prognosis of COVID-19 patients with Type 2 Diabetes Mellitus (T2DM) through an inflammatory pathway. This uncertain aspect brings a new perspective related to insulin use in this pandemic era. OBJECTIVE: We tried to collect and analyze various studies related to this issue to provide a complete picture of the prognosis of insulin use in COVID-19 patients with T2DM. METHODS: We comprehensively searched PubMed, Cochrane CENTRAL, Embase, EBSCO CINAHL, MEDLINE, and grey literature databases for studies investigating the effect of insulin on COVID-19 outcomes, including mortality, hospitalization, disease progression, other prognostic surrogates. Records were screened against the eligibility criteria. RESULTS: 2556 articles were retrieved and were screened. A total of 8 studies were included in the final analysis. There are no studies with solid evidence supporting the effect of insulin treatment on the worsening of the prognosis of COVID-19 patients with T2DM. Although several studies have shown that insulin is associated with a poor prognosis, most studies have not considered confounders. This certainly makes it challenging to analyze the effects of insulin independently. CONCLUSION: We propose that COVID-19 patients with T2DM continue to receive insulin, but with careful observation of the risk of disease progression.

A comparative study of melasma severity after hyperthyroid therapy in hyperthyroid subjects with melasma.

INTRODUCTION: Melasma, and its variant chloasma, is an acquired and chronic disorder of hyperpigmentation, characterized by symmetrical hypermelanoses of the face. The exact pathogenesis of melasma remains unclear. Several hormones are thought to play a role, including thyroid hormones. The study's objectives are to determine the proportion of melasma cases in hyperthyroid patients and to compare the severity of melasma before and after medications of hyperthyroid therapy. METHODS: A quasi-experimental (pre-post intervention) study was conducted in Jakarta from August 2019 to February 2020. Twenty-three patients either newly diagnosed with hyperthyroidism or that had undergone hyperthyroid therapy for a maximum of 3 months and also had melasma were recruited. The severity of melasma was scored with the modified Melasma Area and Severity Index (mMASI), and dermoscopy of the lesions was performed. The evaluation was performed after 3 months of hyperthyroid therapy. RESULTS: Among the 69 hyperthyroid patients, 45 (65%) had melasma. The mean difference in the mMASI score was 0.49 (p > 0.05). Dermoscopy features did not show any differences between the start and end of the study. CONCLUSIONS: There is no significant improvement of melasma severity in hyperthyroid patients after 3 months of hyperthyroid therapy.

Serum TSH level as predictor of Graves' disease recurrence following antithyroid drug withdrawal: A systematic review.

Graves' disease (GD) has a high recurrence rate despite various and adequate treatment. Numerous studies have been performed to identify the predictor of disease recurrence. This report aims to investigate the role of thyroid stimulating hormone (TSH) level as a thyrotropin in predicting the recurrence of Graves' disease within 1 to 2 years following antithyroid drug (ATD) withdrawal. Literature searching was conducted on PubMed, Scopus, Cochrane, Proquest, EBSCO in August 2019 and Google Scholar in October 2020. The study criteria include the study that evaluates TSH level 4 weeks following ATD withdrawal, with subjects ≥18 years old who are retrospectively or prospectively followed up after 1 to 2 years following ATD withdrawal. Four eligible studies were selected based on inclusion/exclusion criteria, all of which measured TSH level at 4 weeks following ATD withdrawal. All studies had 1 to 2 years follow up. One study was an RCT, two studies were done in prospective cohort and another in retrospective cohort. All studies had comparable validity and applicability. Three out of four studies suggested that low TSH level measured 4 weeks following treatment withdrawal was associated with higher risk of disease recurrence. In conclusion, low TSH level obtained 4 weeks after ATD withdrawal was associated with higher rate of recurrence rate in GD.

The Differential Effects of Propylthiouracil and Methimazole as Graves' Disease Treatment on Vascular Atherosclerosis Markers: A Randomized Clinical Trial.

Background: Hyperthyroidism is related to vascular atherosclerosis. Propylthiouracil (PTU) and methimazole, other than their antithyroid effects, may have different mechanisms in preventing atherogenesis in Graves' disease. Objective: This study aimed to investigate the effect of antithyroid drugs on markers of vascular atherosclerosis in Graves' hyperthyroidism. Methods: This study was a single-blind, randomized clinical trial conducted on 36 patients with Graves' disease in Cipto Mangunkusumo General Hospital, Jakarta, Indonesia, from June 2019 until July 2020. Graves' disease was diagnosed from clinical manifestation of hyperthyroidism with diffuse goiter and then confirmed by thyroid stimulation hormone (TSH), free T4 (fT4), and TSH-receptor antibody (TRAb) measurements. Participants were randomly assigned to either a PTU or a methimazole treatment group and followed up for 3 months. Markers of vascular atherosclerosis were represented by adhesion molecules [intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin], carotid artery stiffness [pulse wave velocity (PWV)], and thickness [carotid intima media thickness (cIMT)]. Results: By the end of the study, 24 participants reached euthyroid condition (13 from the PTU group and 11 from the methimazole group). After 3 months of follow-up, in the PTU group, we noticed an improvement of ICAM-1 [pretreatment: 204.1 (61.3) vs. posttreatment: 141.6 (58.4) ng/ml; p = 0.001], VCAM-1 [837 (707-977) vs. 510 (402-630) ng/ml; p < 0.001] and E-selectin [32.1 (24.1-42.7) vs. 28.2 (21.6-36.8) ng/ml; p = 0.045] in the PTU group. In the methimazole group, only VCAM-1 improvement [725 (565-904) vs. 472 (367-590); p = 0.001] was observed. Meanwhile, we found no significant changes in PWV or cIMT in either group. Conclusion: Antithyroid treatment in Graves' disease leads to improvement in adhesion molecules, with a lesser effect on methimazole, whereas there were no significant changes in PWV or cIMT. PTU may have a better mechanism compared with methimazole in terms of improving adhesion molecules.

Adaptation of internet-based multiple mini-interviews in a limited-resource medical school during the coronavirus disease 2019 pandemic.

The coronavirus disease 2019 pandemic has affected many aspects of life, including medical education. The selection of students using multiple mini-interviews (MMI) should be adapted promptly as internet-based MMI (iMMI) in the current setting. The current transition from MMI to iMMI is supported by experience in conducting conventional MMI in previous years; hence, the station and assessor preparation could be completed without significant issues. The greater challenges to the use of iMMI are due to technical issues, including poor internet connections and adaptations necessary for assessing candidates' nonverbal expressions. This paper aims to describe the experience of conducting iMMI in the current pandemic situation, with further highlights on contextual challenges in a limited-resource setting.

A comparison of serum zinc levels in melasma and non-melasma patients: a preliminary study of thyroid dysfunction.

INTRODUCTION: Melasma is an acquired hyperpigmentation disorder, clinically identified by symmetrical blackish-brown macules, especially on the facial area. Several factors are thought to play a role, including thyroid dysfunction and zinc deficiency. The aim of this study was to determine serum zinc levels in melasma and non-melasma patients with and without thyroid dysfunction. METHODS: A cross-sectional study was conducted in Jakarta in September 2019. There were 60 melasma patients and 60 non-melasma patients. The two groups were matched for age and sex. Atomic absorption spectrophotometry was used to measure serum zinc levels. Blood laboratory tests were used to check thyroid function by measuring thyroid stimulating hormone and free T4. Statistical analysis was performed using SPSS software. RESULTS: The mean serum zinc level in the melasma group was 10.25 ± 1.89 µmol/l and in the non-melasma group 10.29 ± 1.46 µmol/l (< 0.901). The mean serum zinc level in melasma patients with thyroid dysfunction was 8.77 ± 0.69 µmol/l, in melasma patients without thyroid dysfunction 10.33 ± 1.89 µmol/l, in non-melasma patients with thyroid dysfunction 10.48 ± 2.4 µmol/l, and in non-melasma patients without thyroid dysfunction 10.27 ± 1.4 µmol/l (< 0.184). CONCLUSIONS: There was no significant difference between serum zinc levels in the melasma and non-melasma groups with and without thyroid dysfunction.

The Risk of Developing Non-Alcoholic Fatty Liver Disease in Adult Patients with Subclinical Hypothyroidism Compared to Euthyroid: An Evidence-based Case Report.

BACKGROUND: hypothyroidism is a common concomitant disease of non-alcoholic fatty liver disease (NAFLD). Previous studies regarding the relationship between subclinical hypothyroidism and NAFLD showed conflicting results, ranging from a strong association to not significant one. This case report aimed to investigate the risk of developing NAFLD in subclinical hypothyroidism patients. METHODS: literature searching used ScienceDirect, PubMed, ProQuest, and Scopus. Filtering process of titles and abstracts by using inclusion and exclusion criteria yielded 4 eligible articles (1 systematic review, 1 prospective cohort, 1 retrospective cohort, and 1 case-control study) for answering the clinical question. Critical appraisal was conducted by using worksheets from Centre for Evidence-Based Medicine, University of Oxford. RESULTS: the systematic review was considered invalid due to its less comprehensive search for relevant studies, inappropriate article selection to find a causal relationship between diseases, and statistical heterogeneity. The retrospective cohort was decided unimportant because it possessed a relative risk of 0.85 (95% confidence interval [CI], 0.72--1.00) which the upper limit of its CI included 1.00. The rest were valid and had important risk relative and odds ratio (1.27 [95% CI, 1.09--1.47], 3.41 [95% CI, 1.16--9.98]; respectively). The number needed to harm (5-17) indicated the clinically meaningful harm of the exposure since only a few patients with subclinical hypothyroidism is needed to obtain one additional NAFLD incidence. Those two articles were also suitable to be applied in our case. CONCLUSION: patients with subclinical hypothyroidism, compared to euthyroid patients, are at higher risk of developing NAFLD.

Diagnostic Approach for Thyroid Nodules.

Thyroid nodule is a health problem which commonly found in daily practice, therefore clinical guidance is needed. This guideline was compiled by a multidisciplinary team and expected to be a guideline in diagnosing thyroid nodules on daily clinical practice.

Practical Guidelines Management of Graves Ophthalmopathy.

Graves' ophthalmopathy is the most common extra-thyroid manifestation in patients with Graves' disease, based on inflammatory and autoimmune conditions in orbital tissue. This practical guideline was formed by a multidiciplinary team, and is intended to provide guidance for diagnosis and management of Graves' ophthalmopathy in daily clinical practice to improve quality of care and treatment outcome.