Risk stratification of persons on premixed insulin in Ramadan.

The International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance, has recently published practical guidelines on the management of diabetes and Ramadan .The risk stratification categorizes all persons wishing to fast into three groups, based upon potential risk. In spite of evidence to the contrary, all persons using premixed insulin are categorized as having high risk. In this article, we present data from randomized controlled trials, and discuss the placement of premixed insulin in the risk stratification framework.

South Asian consensus guideline: Use of GLP-1 receptor agonists during Ramadan: Update 2016 Revised Guidelines on the use of GLP-1A in Ramadan.

This guidance is an update to the South Asian Consensus Guideline: Use of GLP1RA 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 glucagon-like peptide1 receptor agonists during Ramadan. The suggestions contained herewith are based upon recently published evidence as well as available basic pharmacological data.

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.

Inferior glenohumeral joint dislocation with greater tuberosity avulsion.

Inferior glenohumeral dislocation is the least common type of glenohumeral dislocations. It may be associated with fractures of the adjacent bones and neurovascular compromise. It should be treated immediately by close reduction. The associated neuropraxia usually recovers with time. Traction-counter traction method is commonly used for reduction followed by immobilization of the shoulder for three weeks. Here, we report a case of inferior glenohumeral joint dislocation with greater tuberosity fracture with transient neurovascular compromise and present a brief review of the literature.

Management of Idiopathic Clubfoot by Ponseti Technique in Children Presenting After One Year of Age.

We conducted a study to determine the effectiveness of the Ponseti technique in the management of idiopathic congenital clubfoot in patients older than 1 year of age. A total of 19 patients with 28 clubfeet (16 males [84.2%], 3 females [15.8%]) were included in the present study. The mean age at presentation was 2.7 (range 1 to 3.5) years. The results of treatment using the Ponseti technique were evaluated using the Pirani and Dimeglio scoring systems. The mean precorrection total Pirani score was 4.84 (range 3.5 to 5.5) and the mean precorrection Dimeglio score was 12.96 (range 10 to 14). The mean postcorrection total Pirani score was 0.55 (range 0 to 1), and the mean postcorrection Dimeglio score was 2.32 (range 2 to 3). These differences were statistically significant (p < .001 and p < .001, respectively). In 92.8% of the feet, satisfactory correction of the deformity was achieved. The mean number of casts applied was 8 (range 5 to 12). All but 1 (3.6%) of the clubfeet required tenotomy to achieve correction. The mean follow-up duration was 2.7 (range 1.5 to 3.5) years. We have concluded that the Ponseti technique is an effective method for the management of idiopathic congenital clubfoot, even in toddlers.

Multiple volar dislocations of the carpometacarpal joints with an associated fracture of the first metacarpal base.

Multiple volar dislocations of carpometacarpal (CMC) joints are uncommon and have been reported rarely. A 25 years old male presented with injury to his left hand 6 days following a road traffic accident. Clinical examination revealed gross swelling of the hand and diffuse tenderness over the carpometacarpal area. His radiographs of the hand showed volar dislocation of the second, third and fourth CMC joints in association with an extra-articular fracture of the base of thumb metacarpal. He was treated by open reduction and percutaneous fixation using Kirschner wires. The functional results were excellent at one year follow-up.

Medial pivot dislocation of talonavicular joint- A rare injury with literature review.

Medial pivot dislocations are dislocation of talonavicular joint (TNJ) medially with calcaneum subluxate beneath the talus with intact calcaneocuboid joint and interosseous ligament. These dislocations have subtle incidence and are mostly related to high energy injuries. These dislocations are easy to reduce having good functional outcome if diagnosed early. We presented two cases of young active patients who sustained injury to their foot after fall from height and road traffic accident. There were diffuse swelling and tenderness over the foot. X-ray showed medial dislocation of TNJ. Closed reduction was done in both patients. One patient needs percutaneous K-wire fixation. At one year follow-up, foot was painless, stable with normal ankle and subtalar motion.

Augmentation of elastic stable intramedullary nail with external fixator in the management of comminuted shaft femur fracture in adolescents.

BACKGROUND: The management of adolescent femur fractures continues to evolve and remains controversial. Currently, operative fixation methods are favoured, offering options such as external fixator, flexible and locked intramedullary nailing, compression and locked plating. Our study aims to introduce a novel approach for treating adolescent femoral shaft fractures by combining an external fixator with an elastic stable intramedullary nail. MATERIAL AND METHODS: We included 32 patients aged 11-16 years with femoral shaft fractures treated using an external fixator augmented elastic intramedullary nail at our institution from August 2015 to January 2019. RESULTS: All patients achieved bony union. We analysed patient's results both clinically and radiologically. On average, the surgery took 77.34 minutes to complete with an average time to union of 13.9 weeks. External fixator and elastic nail removal took an average of 3.59 months and 26.5 months, respectively. At the final follow-up, knee range of motion averaged 131.88 degrees. According to the Flynn criteria, functional outcomes were excellent in 18 patients, satisfactory in 11 patients and poor in 3 patients. Pin site infection occurred in 3 patients, malunion in 4 patients, limb length shortening < 1 cm in 3 patients, distal nail tip prominence and knee stiffness in 3 patients. CONCLUSION: The management of femur fractures in adolescents using an elastic nail augmented with an external fixator is a minimally invasive procedure that provide secure fracture stabilization and predictable outcomes.

Outcomes of BDSF technique for osteosynthesis of femoral neck fractures.

INTRODUCTION: Femoral neck fractures present a significant challenge for orthopedic surgeons, especially in young patients who want to preserve their natural femoral head. Conventional methods for fixing these fractures often lead to poor outcomes and high complication rates. The Biplane Double-supported Screw Fixation (BDSF) technique is a novel approach that involves placing screws in two planes simultaneously, creating a two-point support for the screws in the neck and head of the femur. METHODS: This study aimed to evaluate the effectiveness of the BDSF technique in treating femoral neck fractures in patients aged 20-60 years. A total of 28 patients with fresh femoral neck fractures (less than three weeks old) were treated with closed reduction and internal fixation using the BDSF method. The patients' functional outcomes were evaluated using the Harris hip score, and the radiographic outcomes of union, femoral neck shortening, screw back-out, and femoral head avascular necrosis (AVN) were also evaluated. RESULTS: The results showed that the BDSF technique is a safe and effective method for treating femoral neck fractures in young adults. Out of the 25 patients who were followed up for a mean time of 18 months (range 6-24 months), 20 (80%) achieved fracture union in a mean time of 5.2 months. Non-union occurred in five patients (20%), and AVN of the femoral head was observed in three patients (12%). Two patients experienced varus collapse, but their fractures united successfully. CONCLUSION: The BDSF technique offers several advantages over conventional methods, including increased stability and improved fixation strength. It can be considered as an alternative to conventional methods for managing femoral neck fractures in young adults, with a low incidence of non-union and avascular necrosis and no cases of fixation failure or varus collapse.

Emphysematous pyelonephritis: experience at a tertiary care hospital in Bangladesh.

BACKGROUND: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma, collecting system and/or perinephric tissues, characterized by gas accumulation. We describe clinical, laboratory and imaging characteristics and in-hospital outcomes of patients with EPN. METHODS: This retrospective observational study was carried out at BIRDEM General Hospital, Dhaka, Bangladesh between 2014 and 2020. RESULTS: We followed 20 patients (mean age 49.4 years; females 70%). Risk factors for EPN were diabetes mellitus (in 100%) and renal stones (in 10%). Fever, loin pain, vomiting and dysuria were common. Complications included acute kidney injury (AKI, 70%; mostly stage 1, 78.6%), hyponatraemia (55%) and bacteraemia (15%). Escherichia coli was the most common (60%) urinary isolate. Most patients (80%) had class 2 EPN, with 15% class 3B and 5% class 3A. Besides medical management, four (20%) required surgery (nephrectomy in 3). Nephrectomised patients had a higher radiological class (p = 0.032) and incidence of AKI (p = 0.034). No deaths occurred. CONCLUSION: EPN occurred predominantly in female diabetic patients, who presented with fever, loin pain, vomiting and dysuria. Two-thirds of patients had AKI and one-fifth required surgery, and there were no deaths.

Management of complex non union of tibia using rail external fixator.

INTRODUCTION: Management of the complex non union of tibia is a challenging task due to infection, bony gap, deformity, poor bone quality and poor soft tissue cover at fracture site. The limb reconstruction system (LRS) or Rail fixator has emerged as a viable option for the treatment of the same as it can address most of all above problems. It is more patient friendly and easier to apply in comparison to Ilizarov ring fixator. MATERIAL AND METHODS: Twenty two patients (17 males and 5 females) with complex non union of tibia underwent thorough debridement and resection of non viable bone followed by bone transport to fill the gap and then lengthening (8 patients) or acute docking & lengthening (14 patients) by the use of rail fixator. The average time to union, bone gap filled, lengthening achieved, treatment index were measured. The bone and functional outcome assessment was done by ASAMI score. The complications were classified according to Paley's classification. RESULTS: Union without residual infection was achieved in 20 (90.1%) patients while 2 patients had failure. As per ASAMI criteria bone results were excellent in 12 (54.5%), good in 5 (22.7%), fair in 3 (13.6%) and poor in 2 (9.1%). Functional results were excellent in 11 (50%), good in 5 (22.72%), fair in 4 (18.18%) and failure in 2 (9%). Mean treatment duration was 8.2 months (range 7-19 months). Mean follow up duration was 11.3 months (range - 8.3 to 22 months). Average lengthening achieved was 4 cm (0-9 cm). Treatment index was 2.1 month/cm. CONCLUSION: The monolateral rail fixator is simple, effective, easier to apply and more patient compliant with acceptable functional and radiological outcome.

Cardiac autonomic neuropathy in patients with type 2 diabetes mellitus having peripheral neuropathy: A cross-sectional study.

AIMS: The aim was to see the frequency of CAN in type 2 diabetes mellitus patients with peripheral neuropathy, and its association with peripheral nerve conduction abnormalities. METHODS: A cross-sectional study at BIRDEM was conducted in 62 patients with type 2 diabetes mellitus having electrophysiologically diagnosed peripheral neuropathy. CAN was detected by four clinical tests - heart rate response to deep breathing and valsalva maneuver, blood pressure response to standing and sustained handgrip. RESULT: The study showed that all patients had CAN - 14.52% had early, 26.67% had definitive and 59.68% had severe CAN. Patients with severe CAN had significantly reduced nerve conduction velocity and amplitude of peripheral nerves (sural 4.36 ±â€¯12.77 vs 9.65 ±â€¯17.77 m/s, p = 0.009; 2.23 ±â€¯1.89 vs 3.01 ±â€¯2.76 mV, p = 0.001; peroneal 7 ±â€¯4.23 vs 8.53 ±â€¯5.99 mV, p = 0.047; tibial 0.008 ±â€¯0.03 vs 0.026 ±â€¯0.05 mV, p = 0.009) and higher serum triglyceride levels (221.17 ±â€¯120.61 vs 197.76 ±â€¯68.43 mg/dl, p = 0.033). CONCLUSION: Diabetic patients with peripheral neuropathy have CAN, the severity of which increases with worsening neuropathy.

Status of Vitamin D and Parathyroid Hormone in Patients Scheduled to Undergo Orthopedic Fracture Management: A Case-Control Study.

BACKGROUND: Vitamin D deficiency (VDD) is seen in all races, age groups, and ethnic backgrounds. VDD estimated to affect >1 billion people worldwide. The purpose of the present study is to characterize the extent of Vitamin D inadequacy and parathyroid hormone (PTH) levels among patients presenting to us for fracture management. MATERIALS AND METHODS: A prospective case-control study was performed whereby serum Vitamin D levels and corresponding PTH levels were measured. The study subjects included patients >45 years of age irrespective of sex who presented with fracture as a result of trivial trauma. A total of 102 cases (34 intertrochanteric fracture, 66 fracture neck of femur, and 2 Colle's fracture) and 100 controls were included in the study. RESULT: Average serum hydroxy-vitamin D and serum PTH of cases 15.8 ± 5.25 ng/mL and 91.15 ± 6.03 pg/mL, respectively. Average S.25-OH Vitamin D and serum PTH of controls was 25.49 ± 3.79 ng/mL and 23.46 ± 3.79 pg/mL, respectively. Eighty (78.4%) cases were in insufficient range (Vitamin D between 10-30 ng/mL), 16 (15.6%) were deficient (Vitamin D <10 ng/mL), and only 6 (5.8%) were sufficient (Vitamin D >30 ng/mL). While in controls, 28% had sufficient and 72% had insufficient Vitamin D levels. There was no deficient control. Serum PTH levels were significantly raised in cases when compared to controls consistent with secondary hyperparathyroidism. CONCLUSION: This study gives us very important data regarding the prevalence of VDD and rise of PTH secondary to the former and this hormonal milieu in our body is an independent risk factor for increased incidence of fracture.

Correction to: Multinational Consensus: Insulin Initiation with Insulin Degludec/Aspart (IDegAsp).

Unfortunately, the fifth author name was incorrectly published in the original publication. The correct name should read as 'Ozgur Demir'.

Multinational Consensus: Insulin Initiation with Insulin Degludec/Aspart (IDegAsp).

Insulin degludec/aspart (IDegAsp) is the first soluble insulin co-formulation, combining a long-acting insulin degludec (IDeg) and rapid-acting insulin aspart (IAsp). In type 2 diabetes patients with oral antidiabetes agent (OAD) inadequacy, insulin initiation with IDegAsp once daily provides superior long-term glycemic control compared to insulin glargine, with similar fasting plasma glucose (FPG) and insulin doses, and numerically lower rates of overall and nocturnal hypoglycemia. Furthermore, in patients with uncontrolled type 2 diabetes previously treated with insulins, IDegAsp twice daily effectively improves glycated hemoglobin and FPG, with fewer hypoglycemic episodes versus premix insulins and basal bolus therapy. In patients with type 1 diabetes mellitus, IDegAsp once daily with two doses of IAsp is a convenient, yet effective, regimen as compared to the conventional 4-5 injection-based basal bolus therapy. IDegAsp is an appropriate and reasonable option for initiation of insulin therapy in both type 1 and type 2 diabetes.

The Bhubaneswar Declaration on Sports Endocrinology, 2018.

Sports and endocrinology are complex interrelated disciplines. Sports and exercise modulate endocrine and metabolic health, and are used to prevent and manage disease. Endocrine and metabolic function influence participation and performance in sports activity. The Bhubaneswar Declaration, released on the occasion of the Endocrine Society of India Conference, resolves to promote the science of sports endocrinology. The authors commit to optimize endocrine health in sports persons, encourage safe use of sports to promote health, and prevent misuse of endocrine interventions in sports.

Expert Opinion: Patient Selection for Premixed Insulin Formulations in Diabetes Care.

Premixed insulins are an important tool for glycemic control in persons with diabetes. Equally important in diabetes care is the selection of the most appropriate insulin regimen for a particular individual at a specific time. Currently, the choice of insulin regimens for initiation or intensification of therapy is a subjective decision. In this article, we share insights, which will help in rational and objective selection of premixed formulations for initiation and intensification of insulin therapy. The glycemic status and its variations in a person help to identify the most appropriate insulin regimen and formulation for him or her. The evolution of objective glucometric indices has enabled better glycemic monitoring of individuals with diabetes. Management of diabetes has evolved from a 'glucocentric' approach to a 'patient-centered' approach; patient characteristics, needs, and preferences should be evaluated when considering premixed insulin for treatment of diabetes.Funding: Novo Nordisk, India.

Attitudes towards genetic diagnosis in Pakistan: a survey of medical and legal communities and parents of thalassemic children.

OBJECTIVES: It was the aim of this study to assess the attitudes of doctors, medical students, lawyers, parliament members and parents of thalassemic children towards genetic diagnosis in Pakistan. STUDY DESIGN: A cross-sectional descriptive survey was conducted among representative samples. RESULTS: Five hundred and seventy doctors, 49 lawyers, 178 medical students, 89 parents of thalassemic children and 16 members of parliament (MPs) were included in the survey. The groups showed considerable difference in their attitudes towards different aspects of the issue. A large proportion (88.5%) agreed to the idea of genetic diagnostic screening, especially the parents of thalassemic patients. Premarital carrier screening was favored by 77% of the respondents. Prenatal screening was most favored by the parents of thalassemic children (94.4%). Likewise, a majority of parents of thalassemic children were in favor of abortion in case of an affected fetus. Genetic self-screening was also favored most by the parents of thalassemic patients (78.2%). Only 24% of the doctors favored making genetic screening mandatory, whereas 63% of the parents agreed to the idea. CONCLUSION: Attitudes regarding genetic diagnosis are markedly different among various societal groups in Pakistan. The parents of the affected children strongly favor genetic screening as does the medical community, though not as strongly as the parents. The legislative groups, particularly the MPs, are reserved in their support. Genetic diagnosis can help decrease the disease burden in the future. However, it raises a number of ethical issues, which need to be addressed. It is important to educate the population about potential benefits as well as ethical dilemmas involved so that the general public is able to make the right decisions for themselves and their families.

Microvascular complications and their associated risk factors in type 2 diabetes mellitus.

AIMS: The aim of this study was to determine the prevalence of microvascular complications and to identify the various risk factors related to these complications in subjects with diabetes. MATERIALS AND METHODS: The study was cross-sectional and conducted in Outdoor of BIRDEM, from July 2014 to December 2014. Subjects were considered at age 30 to 60 years and duration of diabetes was 2-10 years. Investigations included socio-demographic, anthropometry and blood pressure. Blood samples were collected for HbA1c, fasting plasma glucose (FBG), 2-h after breakfast (2-hBG), total cholesterol (chol), triglyceride (TG), LDL, HDL, Hb% and serum creatinine. All the complications were taken from the medical record books which was diagnosed by physician. RESULTS: A total of 400 type 2 diabetes mellitus patients were investigated in this study. The mean and SD of age was 50.05±7.54. The male and female subjects were 41.5% and 58.5% respectively. The prevalence of diabetic retinopathy, nephropathy, neuropathy was 12.3%, 21.3% and 16.8% respectively. Logistic regression model estimated that increasing age (age>50y; OR=3.04; p=<0.001), female participants (OR=1.35; p=<0.04), rural patients (OR=3.75; p=<0.001), housewife (OR=1.89; p=<0.01) and retired patients (2.50; p=<0.03), lack of physical exercise, increasing HbA1c (p=<0.001), FBG (p=<0.001), 2-hBG (<0.001) and blood pressure (p=0.000) had independent significant risk factors for any of three microvascular complications. CONCLUSION: This study observed that about all the microvascular complications were developed from first three years after registration at BIRDEM. Increasing age, HbA1c, FBG, 2-hBG and blood pressure had significant risk factors for any type of microvascular complications.