Diabetes related knowledge among residents and nurses: a multicenter study in Karachi, Pakistan.

BACKGROUND: Assessment of knowledge among resident trainees and nurses is very important since majority of patients admitted in hospital have underlying diabetes which could lead to adverse clinical outcomes if not managed efficiently. Therefore, the purpose of this study was to evaluate and compare the knowledge related to the management of diabetes among registered nurses (RN) and trainee residents of internal medicine (IMR), family medicine (FMR) and surgery (SR) at tertiary care hospitals of Karachi, Pakistan. METHODS: A validated questionnaire consisting of 21 open ended questions related to diabetes awareness was acquired through a study done at Thomas Jefferson University Hospital, Philadelphia with the permission of primary author. RESULTS: 169 IMR, 27 FMR, 86 SR and 99 RN completed a questionnaire that assessed the knowledge related to different aspects of management of diabetes. The results were further stratified by participant's specialty and level of training. The percentage of knowledge based questions answered correctly was found to be low. The overall mean correct percentage among all the participants was 50% +/- 21. There was no statistical difference in terms of knowledge between IMR & FMR residents (64% +/- 14 vs. 60% +/- 16, p = 0.47) respectively. The total scores of SR and RN were quite low (40% +/- 16 & 31% +/- 15 respectively).SR and RN were found to have profound deficit in both inpatient and outpatient knowledge of diabetes. We did not observe any improvement in level of knowledge of FMR & SR with increase in duration of their training (p = 0.47 & 0.80 respectively). In contrast, improvement in the level of knowledge of IMR was observed from first to second year of their training (p = 0.03) with no further improvement thereafter. RN's didn't respond correctly on most of the items related to in-patient management of diabetes (Mean score 40% +/- 20). CONCLUSION: As there are no prior studies in our setting evaluating knowledge related to diabetes management among residents and nurses, this study is of paramount importance. Based on these results, considerable knowledge gaps were found among trainee residents and nurses pointing towards need of providing additional education to improve the delivery of diabetes care.

Does choice of therapy save costs and improve outcomes in hyperthyroid patients?

OBJECTIVE: To compare cost of treating hyperthyroidism with antithyroid medications (ATD) versus radioactive iodine (RAI). As secondary outcome we also analyzed data in terms of remission rates. METHODS: This was a retrospective comparative analysis of hyperthyroid patients treated with ATD or RAI from January 2000 to December 2005. Cost of ATD, TSH. FT4, doctors visits; thyroid technetium scan and RAI treatment were calculated for the duration of treatment and for one year of follow-up after remission. RESULTS: A total of 143 patients were included, with an average duration of follow-up of 32 months. Mean age was 41 +/- 15.5 years and M: F' ratio was 1: 2. More expenses were incurred in treating patients with ATD (Rs. 28,900 +/- 15 400 or US$ 481.67 +/- 256.67) than with RAI (Rs.18.800 +/- 15800 or US$313.33 +/- 263.33). The former cost Rs.10,100 (US$ 168.33) more, (p < 0.001; 95%). Remission rate in the RAI group were significantly higher than the ATD group (81.3% vs 49.5%, p = 0.006). CONCLUSION: Treatment of hyperthyroid patients with RAI is not only better in terms of remission of disease, but it is also a more cost effective modality, and should be considered as first line of treatment.

Vitamin D Deficiency in ambulatory patients.

OBJECTIVE: To determine the frequency of subclinical vitamin D deficiency in an ambulatory care setting. METHODS: This was an observational study which measured 25 vitamin D levels in medical clinic patients. Patients with chronic renal failure, known osteomalacia and rickets were excluded. A total of 119 patients were evaluated. They were divided in three diagnostic categories based on their serum 25 vitamin D levels. Those with levels below 8 ng/ml were categorized to have severe deficiency, levels between 8 - 20 ng/ml as moderate deficiency and levels of 21-35 mg/ml as mild deficiency. RESULTS: Of 119 patients, 92% had vitamin D deficiency. Their mean age was 44.3 +/- 18.3 years, with female to male ratio of 5:1. Sixty two percent (62%) had severe, 24% moderate and 8% had mild deficiency. Nearly half of all these patients (including those with severe deficiency) were asymptomatic. Whereas a low serum calcium, elevated phosphate and elevated alkaline phosphatase were reflective of severe deficiency. It was only an elevated iPTH that correlated with mild to moderate deficiency. CONCLUSION: Subclinical vitamin D deficiency is extensive in the adult ambulatory care patients. Serum calcium, phosphate and alkaline phosphatase are poor markers of moderate to mild deficiency. A serum 25 vitamin D level and an iPTH are better biofunctional markers of this deficiency.

Hyponatraemia: etiology, management and outcome.

OBJECTIVE: To determine the etiology of hyponatraemia, the treatment instituted and the outcome of treatment in a tertiary care hospital setting. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, between January and June 2004. METHODOLOGY: Case records of 220 patients admitted to the medical service were identified through computerized hospital patients' data. All patients (3) 15 years with a sodium level on admission of (2) 130 mmol/litre were included. The records of those patients were reviewed for relevant demographic, clinical and laboratory data, in addition to the diagnosis, treatment and outcome of hospitalization. The data was analyzed through SPSS software version 11.0. RESULTS: Over a 6-month period, 220 patients were admitted with hyponatraemia (serum sodium (2) 130 mmol/L). Of those 127 females and 93 males, the mean age was 65 + 13.29 years. Neurological symptoms were the presenting feature in 25% patients. The mean serum sodium level on admission was 119.46 mmol/L. The rate of correction was >10 mmol/L/ 24 hours in 17% patients. The average duration of stay was 4 days. The mortality was 6.8%. Medicines accounted for 30% cases of hyponatraemia, of which diuretics, angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARBs) were top of the list. Other causes were gastrointestinal in 25%, chest infection in 11% patients, depletional hyponatraemia in 10% patients, SIADH (Syndrome of Inappropriate Antidiuretic Hormone) in 6% patients, congestive cardiac failure and malignancy in 5% each and chronic liver disease in 3.6% patients. CONCLUSION: Hyponatraemia was seen more commonly in the elderly, major causes being gastrointestinal losses and use of drugs. Serum sodium correction should be less than 10 mmol/L/24 hours. The treatment plan be directed to correction of the underlying cause. Diagnosis of SIADH should be sought with appropriate investigation.

Vitamin B12 deficiency common in primary hypothyroidism.

OBJECTIVE: To assess the prevalence and clinical features of B12 deficiency in hypothyroid patients and to evaluate clinical response in symptoms to B12 replacement therapy. METHODS: One hundred and sixteen hypothyroid patients from our endocrine clinic were evaluated for signs and symptoms of vitamin B12 deficiency. Laboratory parameters including Haemoglobin (Hb), MCV, Vitamin B12 levels and presence of anti thyroid antibodies were analyzed. Patients with low B12 levels were treated with parenteral intramuscular vitamin B12 monthly, and monitored for improvement of symptoms. RESULTS: A total of 116 patients (95 females and 21 males) were evaluated. Forty six (39.6%) hypothyroid patients had low vitamin B12 levels. Males and females had the same prevalence of B12 deficiency. Generalized weakness, impaired memory, depression, numbness and decreased reflexes were more frequently noted in B12 deficient patients, but failed to achieve statistical significance when compared with B12 sufficient patients. The mean Hb in B12 deficient group was 11.9 +/- 1.6 mg/dl and 12.4 +/- 1.7 mg/dl in the B12 sufficient group, however the mean MCV did not differ in the two groups. Patients with B12 deficiency did not have a higher prevalence of anaemia. Thyroid antibodies were checked in half the patients and 67% had positive titers for anti thyroid antibodies. Prevalence of vitamin B12 deficiency did not differ in patients with positive antibodies (43.2%) compared to those with negative antibodies (38.9%) (p= 0.759). Twenty four hypothyroid patients with B12 deficiency received intramuscular vitamin B12 injections monthly and improvement in symptoms was noted in 58.3% of these subjects. Additionally, 21 subjects complained of symptoms consistent with B12 deficiency but who had normal range B12, levels and were prescribed monthly B12 injections and 8 (40%) had good subjective clinical response at 6 months. CONCLUSIONS: There is a high (approx 40%) prevalence of B12 deficiency in hypothyroid patients. Traditional symptoms are not a good guide to determining presence of B12 deficiency. Screening for vitamin B12 levels should be undertaken in all hypothyroid patients, irrespective of their thyroid antibody status. Replacement of B12 leads to improvement in symptoms, although a placebo effect cannot be excluded, as a number of patients without B12 deficiency also appeared to respond to B12, administration.

Knowledge about osteoporosis among healthy women attending a tertiary care hospital.

INTRODUCTION: To determinate the knowledge on osteoporosis-risk factors and disease in three age groups of Pakistani women. METHODS: In this exploratory cross-sectional study, an osteoporosis knowledge assessment questionnaire (OKAT) was used to collect data and it was delivered through a face-to-face interview. Questions were asked about symptoms of osteoporosis, knowledge of risk factors, preventive factors and treatment. A convenience sample (n =320) comprising of three groups of healthy women aged 25-35 years, 36-45 years, and over 45 years was taken. The scoring range was 0 to 20. Among-group comparisions of means were analyzed by two-way ANOVA. To determine the overall influence of osteoporosis-risk factors, the multivariate analysis was used. RESULTS: The knowledge on osteoporosis in younger women was very poor compared to relatively older females. However, women belonging to higher socioeconomic status and better education had slightly more knowledge about osteoporosis compared to those with a low education level, regardless of age. CONCLUSION: The majority of women had modest knowledge on osteoporosis. Younger women were at increased risk for low bone mass and premature osteoporosis.

Utility of MRI in assessment of pituitary iron overload.

Beta thalassemia is highly prevalent in Pakistan with a carrier rate of 5-8%. The main complication of beta thalassemia major is iron overload, especially in reticuloendothelial system, heart, joints and endocrine glands. Pituitary siderosis leads to hypogonadotropic hypogonadism and growth hormone deficiency. Measures of plasma ferritin levels and hepatic iron level are used for assessing body iron overload but these are limited for various reasons particularly in case of pituitary siderosis. Magnetic Resonance Imaging (MRI) is a reliable, non invasive and easily available utility for assessing tissue siderosis. We assessed a 20 year old female beta thalassemic diagnosed with hypogonadotropic hypogonadism and pituitary siderosis using routine spin echo (SE) T1 and T2 weighted sequences of MRI and special Gradient Recalled Echo (GRE) sequence of MRI. We found MRI signal intensity to be decreased on all three sequences but most so on GRE suggesting its greatest sensitivity to pituitary iron deposition. MRI signal hypo-intensity due to paramagnetic effects of iron has been validated for liver siderosis but is still under investigation for pituitary siderosis. Our findings suggest that MRI especially GRE sequence can be used in conjunction with laboratory data to evaluate pituitary siderosis and to prevent further pituitary dysfunction.

Rare among the rarities--recurrent insulinoma.

A patient with recurrent insulinoma without co-existing multiple endocrine neoplasia syndrome is described. In a 32-year-old man with recurrent episodes of symptomatic hypoglycemia, the supervised fast showed high insulin (24.5 IU/ml) and C-peptide level (3.06 ng/ml) with low blood sugar (27 mg/dl). A 1 x 1.5 cm nodule from the lower part of pancreatic body was removed on exploratory laparotomy. Histopathology confirmed the diagnosis of islet cell tumor. After 11 years, he started experiencing symptomatic hypoglycemic episodes with inappropriately elevated serum insulin and C-peptide levels (2.2 ng/ml). On pancreatic angiography, a 16 x 11 mm size tumor blush was noted. Due to fibrosis from previous surgery, distal pancreatectomy along with splenectomy was done. Histopathology confirmed the diagnosis of insulinoma. On both occasions, workup for multiple endocrine neoplasia turned out to be negative. He was given small amounts of intermediate acting insulin in early postoperative period, which was discontinued shortly thereafter.

Cushing's disease and pregnancy: case report and literature review.

OBJECTIVE: To describe a patient with untreated Cushing's disease who had 2 spontaneous pregnancies that resulted in healthy babies on both occasions. METHODS: We present a case report with clinical, laboratory, and imaging data and discuss the literature pertaining to pregnancy in patients with Cushing's syndrome. RESULTS: A 28-year-old woman came to our endocrinology clinic with a 1-year history of symptoms and signs of Cushing's syndrome. An elevated 24-hour urinary cortisol excretion and an unsuppressed 1-mg overnight dexamethasone test confirmed the diagnosis. On her next visit, she reported a confirmed pregnancy, which ultimately resulted in the birth of a normal child. Further work-up subsequently showed 2 elevated 24-hour urinary cortisol values, loss of diurnal variation, and an elevated corticotropin level. There was lack of suppression on low-dose and high-dose overnight dexamethasone suppression tests. Magnetic resonance imaging of the pituitary showed normal findings. Inferior petrosal sinus sampling was recommended, but she declined the procedure. The patient returned 3 years later for reevaluation, at which time she reported the birth of another healthy child by cesarean delivery 10 months previously. There were no reported maternal or fetal complications. Examination at this visit revealed buccal pigmentation and proximal myopathy. Investigations showed increased 24-hour urinary cortisol excretion and serum corticotropin levels. Repeated magnetic resonance imaging disclosed a microadenoma on the right side of the pituitary. Unstimulated inferior petrosal sinus sampling showed a gradient to the right; thus, the presence of pituitary-dependent Cushing's disease was confirmed. CONCLUSION: Our case demonstrates that patients with pituitary-dependent Cushing's disease are more likely to have spontaneous pregnancies with favorable outcomes than are patients with Cushing's syndrome due to other causes. Our patient, despite having Cushing's disease for more than 7 years, had 2 uneventful pregnancies that produced normal healthy children, without exacerbation of her disease during pregnancy.

Laparoscopic adrenalectomy for Conn's syndrome.

Laparoscopic adrenalectomy is now used worldwide to resect adrenal adenomas and other adrenal tumors recently introduced in Pakistan. Two cases of endocrine hypertension, due to Conn s syndrome, undergoing laparoscopic adrenalectomy for the first time here, are reported.

Parathyroid apoplexy manifesting as fever of unknown origin.

OBJECTIVE: To describe a rare clinical presentation of necrosis of a parathyroid adenoma, manifesting as fever of unknown origin. METHODS: We present a case report, including detailed clinical and laboratory data, of a patient with previously undiagnosed primary hyperparathyroidism in whom necrosis of a parathyroid adenoma developed during a psychiatric admission for depression. RESULTS: A 40-year-old woman was admitted with severe depression. During her hospitalization, she was found to have osteitis fibrosa cystica, pathologic fractures of her left femur, and primary hyperparathyroidism. Shortly after her admission, spontaneous necrosis of her parathyroid adenoma developed, in association with high-grade fever, acute hypercalcemic crisis, neck pain, hypophonia, and shortness of breath. Findings on extensive evaluation of the fever remained unremarkable, with persistent high-grade temperatures that resolved postoperatively. CONCLUSION: Spontaneous necrosis of a parathyroid adenoma is a rare but well-documented complication of primary hyperparathyroidism. Fever, a previously undocumented associated finding, might be a part of the clinical syndrome of this complication.