A retrospective study comparing the results of continuous glucose monitoring to self-blood glucose monitoring for pregnant women with type 1 diabetes mellitus.

BACKGROUND: Type 1 diabetes mellitus (T1DM) is associated with adverse maternal and fetal outcomes. Continuous glucose monitoring (CGM) during pregnancy is associated with better glycemic control in women with T1DM. However, no clear benefits have been demonstrated in reducing adverse feto-maternal outcomes in pregnant women with T1DM. DESIGN AND METHODS: This is a retrospective, single-center study of pregnant women with T1DM to evaluate the impact of CGM use on glycemic control and feto-maternal outcomes in pregnant women with T1DM. RESULTS: Of 265 women with T1DM, 92 (34.7%) used CGM, and 173 (65.3%) were managed with capillary blood glucose (CBG) monitoring. The mean (SD) age and BMI at the first visit were 29.4 (4.7) years and 27.2 (5.2) kg/m2, respectively. The mean (SD) HbA1c at the first-trimester visit was 63 (1) mmol/mol, and in the last trimester was 51 (1%). There was no difference in the mean changes in HbA1c between the two groups. Women using CGM had lower insulin requirements (1.02 + 0.37 vs. 0.87 + 0.04 units/kg, p = 0.01). The two groups had no significant differences in maternal or fetal outcomes. CONCLUSION: CGM use in pregnant T1DM women is not associated with improved fetomaternal outcomes.

Successful medical management of a pituitary macroadenoma with features of resistant acromegaly and hyperprolactinemia using pasireotide.

BACKGROUND: The somatostatin analog, pasireotide, is used for the treatment of acromegaly after the failure of surgery and/or first-line medical treatment. CASE PRESENTATION: A 48-year-old male reported that during a workup for obesity in his home country, hyperprolactinemia was diagnosed and a 3.5 × 3.5 cm pituitary macroadenoma was identified on pituitary MRI. He received cabergoline for 6 months; then he was lost to follow-up. He presented at our Endocrine clinic 2 years later for treatment of obesity (BMI 49.5 kg/m2). Biochemical workup revealed that in addition to hyperprolactinemia (7,237 [normal: 85-323 mIU/L), he had acromegaly, evident by elevated insulin-like growth factor 1 (IGF-1) level (450 [normal: 88-210 µg/L]), and a positive growth hormone suppression test, secondary hypothyroidism, and secondary hypogonadism. Pituitary MRI showed that the adenoma encased parts of the left and right internal carotid arteries and encroached on the optic chiasm. Surgical excision was therefore not feasible. He was treated with cabergoline and later, long-acting release (LAR) octreotide. Prolactin levels were reduced with cabergoline, but IGF-1 levels did not respond to octreotide, and it was discontinued. The patient abandoned radiotherapy after two sessions. He was started on LAR pasireotide 40 mg every 4 weeks and continued on cabergoline 0.5 mg per week. His biochemical response was dramatic, with a near normalization of IGF-1 levels in 3 months. After 6 months from starting pasireotide, we increased cabergoline dose from 0.5 mg/week to 3 mg/week. Three months later, IGF-1 level was normalized. The patient developed type 2 diabetes as a side effect of pasireotide; however, this was well-controlled with medications. CONCLUSIONS: The case suggests that pasireotide can provide marked biochemical improvement in acromegaly after the failure of both cabergoline monotherapy and cabergoline plus octreotide. This further confirms a potentially efficacious treatment regimen in treatment-resistant acromegaly with hyperprolactinemia.

Oxidative stress, inflammation, and steatosis elucidate the complex dynamics of HgCl2 induced liver damage in Channa punctata.

Water bodies are highly pollution-prone areas in which mercury (Hg) is considered as a major menace to aquatic organisms. However, the information about the toxicity of mercuric chloride (HgCl2) in a vital organ such as the liver of fish is still inadequate. This study aimed to assess the impact of mercuric chloride (HgCl2) exposure on the liver of Channa punctata fish over 15, 30, and 45 days, at two different concentrations (0.039 mg/L and 0.078 mg/L). Mercury is known to be a significant threat to aquatic life, and yet, information regarding its effects on fish liver remains limited. The results of this study demonstrate that exposure to HgCl2 significantly increases oxidative stress markers, such as lipid peroxidation (LPO) and protein carbonyls (PC), as well as the levels of serum glutamic-oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) in the fish. Additionally, the transcriptional and protein analysis of specific genes and molecules associated with necroptosis and inflammation, such as ABCG2, TNF α, Caspase 3, RIPK 3, IL-1ß, Caspase-1, IL-18, and RIPK1, confirm the occurrence of necroptosis and inflammation in the liver. Histopathological and ultrastructural examinations of the liver tissue further reveal a significant presence of liver steatosis. Interestingly, the upregulation of PPARα suggests that the fish's body is actively responding to counteract the effects of liver steatosis. This study provides a comprehensive analysis of oxidative stress, biochemical changes, gene expression, protein profiles, and histological findings in the liver tissue of fish exposed to mercury pollution in freshwater environments.

Prevalence and prognosis of fulminant type 1 diabetes mellitus in The Middle East: a comparative analysis in a 5-year nationwide cohort.

PURPOSE: To analyze the prevalence and progression of fulminant type 1 diabetes (FT1D) in Qatar. METHODS: This retrospective study analyzed consecutive index- diabetic ketoacidosis (DKA) admissions (2015-2020) among patients with new-onset T1D (NT1D) in Qatar. RESULTS: Of the 242 patients, 2.5% fulfilled the FT1D diagnostic criteria. FT1D patients were younger (median-age 4-years vs.15-years in classic-T1D). Gender distribution in FT1D was equal, whereas the classic-T1D group showed a female predominance at 57.6% (n = 136). FT1D patients had a mean C-peptide of 0.11 ± 0.09 ng/ml, compared to 0.53 ± 0.45 ng/ml in classic-T1D. FT1D patients had a median length of stay (LOS) of 1 day (1-2.2) and a DKA duration of 11.25 h (11-15). The median (length of stay) LOS and DKA duration in classic-T1D patients were 2.5 days (1-3.9) and 15.4 h (11-23), respectively. The FT1D subset primarily consisted of moderate (83.3%) and severe 916.7%) DKA, whereas classic T1D had 25.4% mild, 60.6% moderate, and 14% severe DKA cases. FT1D was associated with a higher median white cell count (22.3 × 103/uL) at admission compared to classic T1D (10.6 × 103/uL). ICU admission was needed for 66.6% of FT1D patients, compared to 38.1% of classic-T1D patients. None of the patients in the FT1D group had mortality, while two died in the classic-T1D group. CONCLUSION: This is the first study establishing the existence of FT1D in ME, which presented distinctively from classic-T1D, exhibiting earlier age onset and higher critical care requirements. However, the clinical outcomes in patients with FT1D seem similar to classic T1D.

A systematic review of literature on Insulin-like growth factor-2-mediated hypoglycaemia in non-islet cell tumours.

INTRODUCTION: Insulin-like growth factor-2 (IGF-2)-mediated hypoglycemia is a rare yet clinically significant entity with considerable morbidity and mortality. Existing literature is limited and fails to offer a comprehensive understanding of its clinical trajectory, management and prognostication. METHODS: Systematic review of English-language articles reporting primary patient data on IMH was searched using electronic databases (PubMed, Scopus and Embase) from any date up to 21 December 2022. Data were analysed in STATA-16. RESULTS: The systematic review contains 172 studies, including 1 Randomised controlled trial, 1 prospective observational study, 5 retrospective observational studies, 150 case reports, 11 case series and 4 conference abstracts. A total of 233 patients were analysed, averaging 60.6 ± 17.1 years in age, with comparable proportions of males and females. The commonest tumours associated with Insulin-like Growth Factor-2-mediated hypoglycaemia were fibrous tumours (N = 124, 53.2%), followed by non-fibrous tumours originating from the liver (N = 21, 9%), hemangiopericytomas (N = 20, 8.5%) and mesotheliomas (N = 11, 4.7%). Hypoglycaemia was the presenting feature of NICT in 42% of cases. Predominant clinical features included loss of consciousness (26.7%) and confusion (21%). The mean IGF-2 and IGF-1 levels were 882.3 ± 630.6 ng/dL and 41.8 ± 47.8, respectively, with no significant correlation between these levels and patient outcomes. Surgical removal was the most employed treatment modality (47.2%), followed by medication therapy. The recovery rate was 77%, with chronic liver disease (CLD) significantly associated with a poor outcome (OR: 7.23, P: 0.03). Tumours originating from fibrous tissues were significantly associated with recovery (p < .001). In the logistic regression model, CLD remained a significant predictor of poor outcomes. CONCLUSION: This systematic review highlights that most non-islet-cell tumour-hypoglycaemia (NICTH) is due to fibrous tumours. NICTs demonstrate a variable prognosis, which is fair if originating from fibrous tissue. Management such as octreotide, corticosteroids, diazoxide, embolization, radiotherapy and surgical resection have disparate success rates.

Clinical characteristics and outcomes of patients with TSH-secreting pituitary adenoma and Graves' disease - a case report and systematic review.

BACKGROUND: Coexistence of TSH-secreting pituitary adenoma (TSHoma) and Graves' disease (GD) is rare and complicates the management decision. METHODS: We present a case of the co-existence of TSHoma and GD. In addition, we systematically searched articles describing TSHoma and GD in the same patient published until 20th March 2023, using Pubmed, Scopus and Embase. CASE PRESENTATION: A 46-year-old man presented with symptoms of thyrotoxicosis. His thyroid function tests showed serum TSH 3.35 (reference range 0.3-4.2) mIU/L, FT3 19.7 (3.7-6.4) pmol/L, and FT4 68.9 (11-23.3) pmol/L. The serum TSH receptor antibody was 11.5 mIU/L (positive at ≥ 1.75 mIU/L). Pituitary magnetic resonance imaging showed macroadenoma compressing the optic chiasm. The patient underwent trans-sphenoidal resection of pituitary adenoma. Postoperatively, he remained on maintenance carbimazole and octreotide. RESULTS: Fourteen articles comprising 15 patients were identified from the systemic search. A total of 16 patients (including the current case) were included in the systematic review. The mean (± SD) age at diagnosis was 41 ± 13.6 years. The majority were females (75%). The median (IQR) TSH was 1.95 (0.12-5.5) mIU/L, the median (IQR) free T3 was 11.7 (7.6-19.7) pmol/L and the median (IQR) free T4 level was 47.6 (33.3-64.4) pmol/L. Ten (76.9%) patients had positive TSH receptor antibody levels. 84.6% had pituitary macroadenoma. Pituitary surgery was performed in 12 (75%) patients. At the last follow-up, 4 (25%) patients had complete resolution of symptoms after pituitary surgery, 3 (18.7%) were on maintenance treatment with thionamides for GD, 1 (6.25%) on beta-blockers and 1 (6.25%) on somatostatin analog. CONCLUSION: TSHoma and GD can co-exist, and it is essential to identify this rare association as it can significantly impact treatment strategies.

Dietary inclusion of Withania somnifera and Asparagus racemosus induces growth, activities of digestive enzymes, and transcriptional modulation of MyoD, MyoG, Myf5, and MRF4 genes in fish, Channa punctatus.

The present study explores growth potential of two medicinal herbs, Withania somnifera (Ashwagandha or 'A') and Asparagus racemosus (Shatavari or 'S') after their dietary inclusion in fish, Channa punctatus (13.5 ± 2 g; 11.5 ± 1 cm). Three hundred well-acclimatized fish were distributed into 10 groups- C (Control), S1 (1% S), S2 (2% S), S3 (3% S), A1 (1% A), A2 (2% A), A3 (3% A), AS1 (1% A and S), AS2 (2% A and S), and AS3 (3% A and S), each having 10 specimens. Fish were fed with these diets for 60 days. The study was performed in triplicate. Growth indices- weight gain (WG), specific growth rate percentage (SGR%), feed intake (FI), and condition factor (CF), after 30 and 60 days, were found significantly (p < 0.05) up-regulated in all the groups, except S1, when compared to the C. A significant (p < 0.05) increase in final body weight (FBW) was noticed in all the groups, except S1, after 60 days. Relative to the control group, activities of lipase and amylase in the gut tissue were elevated in all groups, at both sampling times, with the exception of lipase in S1 at 60 days, and amylase in S1 at day 30 and day 60 and S2 at day 60. The mRNA expression of myogenic regulatory factors (MRFs) was also found to be significantly (p < 0.05) up-regulated with the highest fold changes recorded in AS3 for myoD (3.93 ± 0.91); myoG (6.71 ± 0.30); myf5 (4.40 ± 0.33); MRF4 (4.94 ± 0.21) in comparison to the C.

Carbimazole-Resistant Grave's Thyrotoxicosis is a Diagnostic and Therapeutic Dilemma, Case Report with Literature Review.

Background: Carbimazole (CBZ) (or methimazole) is the most used drug inducing and maintaining remission in thyrotoxicosis, especially Grave's disease (GD). Rarely, situations arise when patients do not respond to recommended or even supratherapeutic doses of CBZ. It poses a challenge to diagnose drug resistance and ultimately manage hyperthyroidism, which can otherwise be fatal if left untreated. Propylthiouracil (PTU) has been used as an alternative in such patients amid increased side effect risks. Additionally, definitive therapy has been recommended with ablation or surgery. However, the best modality of inducing euthyroidism in drug-resistant patients is yet to be established. On literature search, twenty similar cases were found in the literature search. This study summarizes the past literature with addition of a new case of anti-thyroid drug resistant (ATDR) GD. Case Presentation: A 34-year-old female presented with a 5-day history of progressively worsening fatigue, heat intolerance, sweating, and palpitations. She was diagnosed with GD based on her thyroid function tests (TFTs) and started on CBZ and propranolol. Despite being compliant with CBZ 20 mg once daily and then twice daily, her TFTs remained unchanged for 4 months. However, patient revisited the emergency with continued thyrotoxicosis and unchanged TFTs. Her dose was eventually increased to 20 mg thrice daily, and administration under supervision did not improve her TFTs. The patient was shifted to PTU 150 mg thrice daily with steroids, with minimal improvement. The patient eventually underwent thyroidectomy to avoid long-term PTU use. Conclusion: ATDR GD is rare and remains a diagnostic and therapeutic challenge. Optimal management should focus on carefully excluding other possibilities and shared decision-making in its management. Most patients may require definitive therapy; hence, arrangements should be made timely with simultaneous attempts to reduce the thyrotoxic state, which otherwise poses a continued threat to patients' life with potentially serious complications.

Medical Admission Prediction Score (MAPS); a simple tool to predict medical admissions in the emergency department.

INTRODUCTION: Overcrowding in the emergency departments (ED) is linked to adverse clinical outcomes, a negative impact on patient safety, patient satisfaction, and physician efficiency. We aimed to design a medical admission prediction scoring system based on readily available clinical data during ED presentation. METHODS: In this retrospective cross-sectional study, data on ED presentations and medical admissions were extracted from the Emergency and Internal Medicine departments of a tertiary care facility in Qatar. Primary outcome was medical admission. RESULTS: Of 320299 ED presentations, 218772 were males (68.3%). A total of 11847 (3.7%) medical admissions occurred. Most patients were Asians (53.7%), followed by Arabs (38.7%). Patients who got admitted were older than those who did not (p <0.001). Admitted patients were predominantly males (56.8%), had a higher number of comorbid conditions and a higher frequency of recent discharge (within the last 30 days) (p <0.001). Age > 60 years, female gender, discharge within the last 30 days, and worse vital signs at presentations were independently associated with higher odds of admission (p<0.001). These factors generated the scoring system with a cut-off of >17, area under the curve (AUC) 0.831 (95% CI 0.827-0.836), and a predictive accuracy of 83.3% (95% CI 83.2-83.4). The model had a sensitivity of 69.1% (95% CI 68.2-69.9), specificity was 83.9% (95% CI 83.7-84.0), positive predictive value (PPV) 14.2% (95% CI 13.8-14.4), negative predictive value (NPV) 98.6% (95% CI 98.5-98.7) and positive likelihood ratio (LR+) 4.28% (95% CI 4.27-4.28). CONCLUSION: Medical admission prediction scoring system can be reliably applied to the regional population to predict medical admissions and may have better generalizability to other parts of the world owing to the diverse patient population in Qatar.

Differential evolution of diabetic ketoacidosis in adults with pre-existent versus newly diagnosed type 1 and type 2 diabetes mellitus.

BACKGROUND: Diabetic ketoacidosis (DKA) was once known to be specific to type-1 diabetes-mellitus (T1D); however, many cases are now seen in patients with type-2 diabetes-mellitus (T2D). Little is known about how this etiology shift affects DKA's outcomes. METHODS: We studied consecutive index DKA admissions from January 2015 to March 2021. Descriptive analyses were performed based on pre-existing T1D and T2D (PT1D and PT2D, respectively) and newly diagnosed T1D and T2D (NT1D and NT2D, respectively). RESULTS: Of the 922 patients, 480 (52%) had T1D, of which 69% had PT1D and 31% NT1D, whereas 442 (48%) had T2D, of which 60% had PT2D and 40% NT2D. The mean age was highest in PT2D (47.6 ± 13.1 years) and lowest in PT1D (27.3 ± 0.5 years) (P < 0.001). Patients in all groups were predominantly male except in the PT1D group (55% females) (P < 0.001). Most patients were Arabic (76% in PT1D, 51.4% in NT1D, 46.6% in PT2D) except for NT2D, which mainly comprised Asians (53%) (P < 0.001). Patients with NT2D had the longest hospital length of stay (LOS) (6.8 ± 11.3 days) (P < 0.001), longest DKA duration (26.6 ± 21.1 h) (P < 0.001), and more intensive-care unit (ICU) admissions (31.2%) (P < 0.001). Patients with PT1D had the shortest LOS (2.5 ± 3.5 days) (P < 0.001), DKA duration (18.9 ± 4.2 h) (P < 0.001), and lowest ICU admissions (16.6%) (P < 0.001). CONCLUSIONS/INTERPRETATION: We presented the largest regional data on differences in DKA based on the type and duration of diabetes- mellitus (DM), showing that T2D is becoming an increasing cause of DKA, with worse clinical outcomes (especially newly diagnosed T2D) compared to T1D.

Incidence of diabetic ketoacidosis does not differ in Ramadan compared to other months and seasons: results from a 6-year multicenter study.

BACKGROUND: Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA. METHODS: We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons. RESULTS: Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25-45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons. CONCLUSIONS: DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar.

Clinical and biochemical predictors of intensive care unit admission among patients with diabetic ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) contributes to 94% of diabetes-related hospital admissions, and its incidence is rising. Due to the complexity of its management and the need for rigorous monitoring, many DKA patients are managed in the intensive care unit (ICU). However, studies comparing DKA patients managed in ICU to non-ICU settings show an increase in healthcare costs without significantly affecting patient outcomes. It is, therefore, essential to identify suitable candidates for ICU care in DKA patients. AIM: To evaluate factors that predict the requirement for ICU care in DKA patients. METHODS: This retrospective study included consecutive patients with index DKA episodes who presented to the emergency department of four general hospitals of Hamad Medical Corporation, Doha, Qatar, between January 2015 and March 2021. All adult patients (> 14 years) fulfilling the American Diabetes Association criteria for DKA diagnosis were included. RESULTS: We included 922 patients with DKA in the final analysis, of which 229 (25%) were managed in the ICU. Compared to non-ICU patients, patients admitted to ICU were older [mean (SD) age of 40.4 ± 13.7 years vs 34.5 ± 14.6 years; P < 0.001], had a higher body mass index [median (IQR) of 24.6 (21.5-28.4) kg/m2 vs 23.7 (20.3-27.9) kg/m2; P < 0.030], had T2DM (61.6%) and were predominantly males (69% vs 31%; P < 0.020). ICU patients had a higher white blood cell count [median (IQR) of 15.1 (10.2-21.2) × 103/uL vs 11.2 (7.9-15.7) × 103/uL, P < 0.001], urea [median (IQR) of 6.5 (4.6-10.3) mmol/L vs 5.6 (4.0-8.0) mmol/L; P < 0.001], creatinine [median (IQR) of 99 (75-144) mmol/L vs 82 (63-144) mmol/L; P < 0.001], C-reactive protein [median (IQR) of 27 (9-83) mg/L vs 14 (5-33) mg/L; P < 0.001] and anion gap [median (IQR) of 24.0 (19.2-29.0) mEq/L vs 22 (17-27) mEq/L; P < 0.001]; while a lower venous pH [mean (SD) of 7.10 ± 0.15 vs 7.20 ± 0.13; P < 0.001] and bicarbonate level [mean (SD) of 9.2 ± 4.1 mmol/L vs 11.6 ± 4.3 mmol/L; P < 0.001] at admission than those not requiring ICU management of DKA (P < 0.001). Patients in the ICU group had a longer LOS [median (IQR) of 4.2 (2.7-7.1) d vs 2.0 (1.0-3.9) d; P < 0.001] and DKA duration [median (IQR) of 24 (13-37) h vs 15 (19-24) h, P < 0.001] than those not requiring ICU admission. In the multivariate logistic regression analysis model, age, Asian ethnicity, concurrent coronavirus disease 2019 (COVID-19) infection, DKA severity, DKA trigger, and NSTEMI were the main predicting factors for ICU admission. CONCLUSION: In the largest tertiary center in Qatar, 25% of all DKA patients required ICU admission. Older age, T2DM, newly onset DM, an infectious trigger of DKA, moderate-severe DKA, concurrent NSTEMI, and COVID-19 infection are some factors that predict ICU requirement in a DKA patient.

A case report of insulinoma presenting with seizures and localized on endoscopic ultrasound.

Insulinomas are rare functioning neuroendocrine (NEN) tumors. Up to 10% of insulinomas are associated with multiple endocrine neoplasia 1 (MEN1). Most of the tumors present with symptomatic hypoglycemia. Several non-invasive and invasive techniques are used to localize the lesion. We present a case of insulinoma presenting with seizure episodes with negative results on non-invasive imaging diagnosed and localized with endoscopic ultrasound. A 36-year-old male was brought by ambulance to the emergency department with an episode of generalized tonic-clonic seizures. He had been previously healthy and did not have family history of neuro-endocrine tumors. At the time of the attack, the patient's blood glucose checked via point-of-care testing was 28.8 (70-99 mg/dL). He was given IV dextrose. Physical examination after the patient regained consciousness was completely unremarkable. Hypoglycemia workup revealed a normal morning cortisol level of 281 (138-689 nmol/L). Insulin level was 62.4 mcunit/ml (2.36-24.9), and c-peptide was 8.13 (1.1-4.4 ng/mL) consistent with hyperinsulinemia. Magnetic resonance cholangiopancreatography (MRCP), fluorine-18-l-dihydroxyphenylalanine whole-body positron emission tomography scan (NM 18F-DOPA whole-body PET scan), and gallium Ga 68 dodecanetetraacetic acid (Ga-68 DOTATATE) scan were normal and did not reveal any pancreatic lesion consistent with insulinoma. Due to high suspicion of insulinoma and negative non-invasive imaging, an endoscopic ultrasound (EUS) was performed, which showed a hypoechoic homogenous mass lesion sized 13 × 9 mm in the proximal body/neck of the pancreas. A fine needle biopsy (FNA) via EUS was performed. Histopathology showed a well-differentiated neuroendocrine tumor, consistent with Grade 1 insulinoma (T1N0M0). The patient underwent a distal pancreatectomy and splenectomy. In cases of high clinical and biochemical suspicion of insulinoma but negative non-invasive imaging, invasive modalities should be used to localize the culprit lesion.

A retrospective study on comparison of clinical characteristics and outcomes of diabetic ketoacidosis patients with and without acute pancreatitis.

The co-existence of diabetic ketoacidosis (DKA) with acute pancreatitis (AP) is associated with unfavorable clinical outcomes. However, diagnosing AP in DKA patients is challenging and often missed due to overlapping symptoms. The aim of this retrospective observational study was to compare the clinical characteristics and outcomes of patients with concomitant DKA and AP or DKA alone. Data of patients with DKA admitted between January 2015 to August 2021 to four hospitals in Qatar was extracted from the electronic health record (Cerner). American Diabetes Association criteria and Atlanta criteria were used for DKA and AP diagnosis, respectively. Independent T-test or Mann-Whitney U test was used to analyze continuous variables, whereas categorical variables were analyzed via Chi-square or Fischer exact tests as appropriate. Univariate and multivariate logistic regression models were generated to assess the correlations. A p-value of < 0.05 was considered statistically significant. Of 936 patients with DKA, 84 (9.0%) had coexisting AP. AP was most common in the Asian race (66%, p < 0.001). Patients with DKA and AP were older, had higher admission anion-gap, white cell count, hemoglobin (hb), neutrophil/lymphocyte ratio, urea, creatinine, maximum blood glucose during the episode, total cholesterol and triglyceride level (TGL) (p < 0.05). They had a lower admission venous pH and bicarbonate at 6 h. Patients in the DKA with AP group also had a longer length of stay (LOS), DKA duration and a higher rate of ICU admission (p-values ≤ 0.001). In-hospital mortality, 3-month all-cause readmission, 6-month and 12-month DKA recurrence did not differ between the two groups. Univariate logistic regression analysis showed age, Asian ethnicity, male gender, T2D, admission WBC count, hb, urea, creatinine, potassium, venous pH, bicarbonate, anion gap, total cholesterol, TGL and LDL level were significantly associated with the development of DKA with AP (p < 0.05). In multivariate logistic regression analysis, age and total cholesterol level were associated with concomitant DKA and AP (p < 0.05). Patients with concomitant DKA and AP have more severe derangement in markers of DKA severity, inflammation, kidney injury and metabolic profile, along with a longer DKA duration, LOS and requirement for ICU support compared to DKA patients without AP. This highlights the clinical significance of diagnosing the co-existence of DKA with AP, as the combination results in significantly worse clinical outcomes and greater healthcare utilization than in patients with only DKA.

Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis.

BACKGROUND: The increasing prevalence of diabetic ketoacidosis (DKA) related admissions poses a significant burden on the healthcare systems globally. However, data regarding the predictors of healthcare resource utilization in DKA is limited and inconsistent. This study aimed to identify key predictors of hospital length of stay (LOS), readmission and recurrent DKA episodes. METHODS: We undertook a retrospective cross-sectional analysis of all DKA admissions from 2015 to 2021 across four hospitals in Qatar. The primary outcomes were the length of stay (LOS), 90-day readmission and 6-month and 1-year DKA recurrence. RESULTS: We included 922 patients with a median age of 35 years (25-45). 62% were males with type-1 diabetes-mellitus (T1DM) and type-2 DM (T2DM), present in 52% and 48% of patients. The median LOS was 2.6 days (IQR 1.1-4.8), and the median DKA resolution time was 18 h (10.5-29). Male-gender, new-onset DM, higher Charlson Comorbidity Index (CCI), lower haemoglobin, sodium and potassium, higher urea, longer DKA duration and MICU admission predicted a longer LOS in a multivariate regression analysis. None of the factors were significantly associated with 90-day readmission. Patients with pre-existing T1DM were more likely to have a six-month DKA recurrence than pre-existing T2DM. Patients with a 6-month DKA recurrence, female gender and T1DM had higher odds of 12-month recurrence, whereas a consult with a diabetes educator at the index admission was associated with decreased odds of recurrence. CONCLUSIONS/INTERPRETATION: This is the most extensive study from the Middle-East region reporting on LOS, readmissions and the recurrence of DKA. Results from this study with a diverse population may be valuable for physicians and healthcare systems to decrease the diabetes-related healthcare burden in DKA patients.

Evaluation of immunostimulatory attributes of Asparagus racemosus and Withania somnifera supplemented diets in fish, Channa punctatus (Bloch, 1793).

With the progression of aquaculture industry, there has been a spurt in dietary supplementation with economically viable medicinal herbs having enough immunostimulatory potential. This also aids in avoidance of environmentally undesirable therapeutics that are almost inevitable to safeguard fish against an array of diseases in aquaculture practices. The study aims to determine the optimal dose of herbs that can stimulate substantial immune response in fish for reclamation of aquaculture. Immunostimulatory potential of the two medicinal herbs- Asparagus racemosus (Shatavari), Withania somnifera (Ashwagandha), individually, and in combination, with a basal diet was screened up to 60 days in Channa punctatus. 300 laboratory acclimatized healthy fish (14 ± 1 g; 11 ± 1 cm) were divided into ten groups- C, S1, S2, S3, A1, A2, A3, AS1, AS2, and AS3, based on the composition of dietary supplementation, in triplicates, with 10 specimens per group. The hematological index, total protein and lysozyme enzyme activity were performed after 30 and 60 days, while qRT-PCR analysis of lysozyme expression was done after 60 days of the feeding trial. The significant (P < 0.05) increments in hematological indices- (TEC, TLC, DLC, Hb, Hct, MCV, MCH and MCHC), total protein content and serum lysozyme activity, after 30 and 60 days; whereas upregulation of lysozyme transcript levels, both in liver and muscle tissues after 60 days of the feeding trial were recorded in groups- AS1, AS2, and AS3. The maximal increment in lysozyme expression was recorded in AS3, both in liver and muscle tissues, with 3.75 ± 0.13 and 3.21 ± 0.18-folds, respectively. However, increments were non-significant (P > 0.05) for MCV in AS2 and AS3 after 30 days; and for MCHC in AS1 for both the durations; whereas in AS2 and AS3, after 60 days of the feeding trial. A positive correlation (P < 0.05) among lysozyme expression, MCH, lymphocytes, neutrophils, total protein content, and serum lysozyme activity in AS3, after 60 days, conclusively, evinces that a 3% dietary supplementation with both A. racemosus and W. somnifera enhances immunity and health profile of the fish, C. punctatus. The study, thus finds ample scope in augmentation of aquaculture production and also paves the way for more researches for biological screenings of potential immunostimulatory medicinal herbs that can be appropriately incorporated in the fish diet.

Clinical Characteristics and Outcomes of Patients With Antithyroid Drug-Related Liver Injury.

Context: Antithyroid drugs (ATDs) are the cornerstone of hyperthyroidism management. Hepatotoxicity due to ATDs can range from mild transaminase elevation to liver transplantation requirement and mortality. Objective: The primary objective of the systematic review was to assess the clinical characteristics and outcomes of patients with drug induced liver injury (DILI) due to ATDs. Methods: We conducted a systematic review of PUBMED, SCOPUS, and EMBASE on characteristics and outcomes of adults (>18 years) with DILI due to ATDs. We defined DILI as bilirubin ≥2.5 mg/dL or international normalized ratio >1.5 with any rise in alanine aminotransferase (ALT), aminotransferase (AST), or alkaline phosphatase (ALP), or an elevation of ALT or AST >5 times or ALP >2 times the upper limit of normal without jaundice/coagulopathy. Results: The review included 100 articles describing 271 patients; 148 (70.8%) were female (N = 209). Mean age was 42.9 ± 17.2 years. Graves' disease was the most common indication for ATDs. Carbimazole/methimazole (CBM/MMI) was the most common offending agent (55.7%). DILI pattern was hepatocellular in 41.8%, cholestatic in 41.3%, and mixed in 16.9%. Outcomes included death in 11.8%, liver transplantation in 6.4%, partial improvement in 2.2%, and complete resolution in 79.6% with a median time (IQR) to resolution of 45 (20-90) days. Patients in the propylthiouracil (PTU) group had higher initial bilirubin, initial AST, initial ALT, peak ALT, peak AST, severe and fatal DILI, liver transplantation, and mortality than CBM/MMI. Rechallenge of antithyroid medication was infrequently reported (n = 16) but was successful in 75%. Conclusion: DILI due to ATDs can present with different patterns and should prompt immediate drug discontinuation. Referral to a hepatologist should be considered if severe as transplantation is sometimes required. PTU-induced DILI may have worse outcomes than CBM/MMI.

The clinical characteristics and outcomes of patients with pulmonary hypertension in association with hyperthyroid state: A systematic review.

BACKGROUND: Pulmonary hypertension (PHTN) may occur in thyroid disorders, especially in hypothyroidism. However, there is increasing evidence of PHTN in hyperthyroidism (HTH). The etiology, clinical course, management, and factors associated with outcomes of PHTN in the setting of HTH are unascertained. This systematic review consolidates available evidence on patients with HTH who developed PHTN. METHODS: We conducted a systematic review on English articles from PubMed, Scopus, and Google Scholar reporting PHTN in patients with hyperthyroidism. Data were analyzed and reported in Microsoft Excel 2020, SPSS version 26, and Jamovi version 1.2. RESULTS: We identified 589 patients with PHTN in the setting of HTH. Etiologies included Grave disease 66.7%), toxic multinodular goiter (TMNG) (16.8%), drug-induced HTH (0.3%), thyroiditis(0.8%), and toxic adenoma(0.1%). Most patients did not receive any specific management for PHTN and were managed by antithyroid treatment (97.4%). Outcomes of PHTN were reported in 181 patients, with a 94% recovery rate. Pulmonary artery pressures (PAP) before and after HTH management ranged from 22.5 to 75 mm Hg and from 24 to 50 mm Hg, respectively. Outcome analysis performed on data from case reports and series with individually identifiable data revealed a 67.6% female preponderance. An estimated 73.5% of the patients had PHTN at the initial presentation of HTH, which was associated with a better resolution rate of PHTN(OR: 12, P-value: 0.048). TRAB was positive in 47% patients with no clinical difference in outcomes. antiTG AB was reported positive in 29.4%, all of whom had an improvement, compared to an 83.3% improvement rate in those with negative antiTG AB. Various etiologies and treatments did not have any significant differences in the outcome of PHTN. CONCLUSIONS: PHTN can be present at the initial diagnosis of HTH, which is associated with better outcomes of PHTN. There is a clear female preponderance in the development of PHTN. However, resolution rates seem to be better in males. Although TRAB is associated with the development of PHTN, it does not seem to affect the outcomes. PHTN in patients with HTH does not need any specific management, with >90% resolution with antithyroid therapy. Whether any specific antithyroid therapy has a better outcome in PHTN needs to be explored prospectively.

Spontaneous tension pneumothorax as a complication of Coronavirus disease 2019: Case report and literature review.

Primary spontaneous tension pneumothorax (STP) is a rare and life-threatening condition. We report a case of COVID-19-pneumonia patient who developed STP as a complication. He had a prolonged hospital stay and was ultimately discharged asymptomatic. A systematic literature search was performed to review studies (N=12) reporting STP in the setting of COVID-19.

Cerebral venous sinus thrombosis as the initial presentation of essential thrombocythemia - A case report and literature review.

Myeloproliferative disorders (MPD) are associated with vascular thrombosis. Common sites for thrombosis are large arteries; however, less commonly, cerebral venous sinus thrombosis (CVST) has also been reported. It is rare to have CVST as an initial presentation of MPD. We discuss a male patient in whose presentation due to CVST led to the diagnosis of essential thrombocythemia (ET). Furthermore, we performed a literature review to evaluate the association of CVST with ET.