Outcomes of Low-Risk Differentiated Thyroid Cancer (DTC) without Radioactive Iodine (RAI) Ablation Therapy Post-Thyroidectomy: An Experience from a Tertiary Centre in Karachi.

OBJECTIVE: To assess the outcomes of low-risk differentiated thyroid cancer (DTC) with tumour size 1 to 4 cm post-thyroidectomy in patients who never received radioactive iodine (RAI) ablation and to compare the outcomes with those who received RAI therapy. STUDY DESIGN: Observational study. Place and Duration of the Study: Department of Nuclear Medicine, Karachi Institute of Radiotherapy and Nuclear Medicine (KIRAN) Hospital, Karachi, Pakistan, from January 2016 to December 2020. METHODOLOGY: A total of 130 consecutive patients of low-risk DTC of both genders aged between 18-75 years were identified who underwent thyroidectomy. Patients were classified as either being treated or not treated with RAI, based on RAI data post-thyroidectomy. Patients were followed up for two to five years depending on their date of diagnosis from 2016 to 2020, using thyroglobulin (Tg), anti-thyroglobulin (anti-Tg), and thyrotropin (TSH) levels and ultrasound neck. Association between patients who received RAI and who did not receive RAI was determined and a p-value <0.05 was considered as statistical significance. RESULTS: Patients had mean age of 34.5 ± 10.4 years with majority of females (75.4%). Majority of the patients (94.6%) had total thyroidectomy with no neck dissection (83.1%). RAI therapy was conducted among 70.8% participants, of which, 56.9% participants received a dose of 100 mci. Most of the patients had positive outcomes as there was no recurrence among 96.2% participants. There was a significant difference in RAI therapy with total thyroidectomy as compared to subtotal, RAI dose, tumour stage, neck dissection, and lymph node involvement (p ≤0.001). CONCLUSION: After complete tumour resection, a highly selected group of patients with low-risk local disease have shown low rate of recurrence when managed without RAI. Interestingly, the disease recurrence was also only seen in patients who received RAI therapy in comparison to those who did not receive RAI therapy. KEY WORDS: Outcomes, Differentiated thyroid cancer, Radioactive iodine, Ablation therapy, Post-surgery.

Persistent Müllerian Duct Syndrome Diagnosed Incidentally: A Case Report.

Persistent Müllerian Duct syndrome is a rare male disorder of sexual development. The phenotypically and genotypically male patient presents with female internal organs (i.e., uterus, cervix, fallopian tubes and upper part of vagina) due to deficiency of anti-mullerian hormone or insensitivity of tissues to Anti Mullerian Hormone. We present a 19 year old male who came with complaint of right iliac fossa pain. He was investigated for acute appendicitis and on imaging, he was diagnosed to have bilateral cryptorchidism with rudimentary uterus. Computed tomography followed by pelvic ultrasonography was done which indicated two testes in abdomen and a soft tissue density structure, identified as a rudimentary uterus located posterior to the urinary bladder. CT scan findings were further confirmed by magnetic resonance imaging pelvis. A trial of stepwise orchidopexy followed by orchidectomy with removal of rudimentary uterus was performed laparoscopically. Additionally, he was counselled for long term sex hormone replacement and reproductive failure in future.

Levothyroxine absorption test followed by directly observed treatment on an outpatient basis to address long-term high thyrotropin levels in a hypothyroid patient: a case report.

BACKGROUND: For the treatment of hypothyroidism, patients are usually placed on lifelong levothyroxine replacement therapy. Achieving clinical and biochemical euthyroid status is sometimes difficult because of several factors, including poor compliance or poor absorption of levothyroxine in the gut mucosa. CASE PRESENTATION: We present the case of a 45-year-old South Asian female with hypothyroidism on lifelong levothyroxine replacement. However, on her multiple follow-up visits over the past 2 years, it was noted that her thyrotropin level was never controlled and was not in range. A thorough history was unyielding in terms of compliance regarding levothyroxine medication and use of over-the-counter pills or mineral supplements that may interfere with the absorption of levothyroxine. Hence, we performed levothyroxine absorption test to rule out any malabsorption as well as document pseudo-malabsorption favoring drug nonadherence. Levothyroxine absorption test resulted in more than 56% absorption of levothyroxine; therefore, the patient was put on weekly directly observed treatment strategy resulting in normalization of thyrotropin levels on successive follow-ups. CONCLUSION: Directly observed treatment to replace levothyroxine once a week can be used as an alternative by health care professionals in patients in whom compliance to daily levothyroxine is the hidden cause of persistently raised thyrotropin. This strategy can reduce undue health burden on the patient and improve adherence to self-medication under confident supervision of the treating physician.

Clinical efficacy of scaling and root planing with and without metronidazole on glycemic control: three-arm randomized controlled trial.

BACKGROUND: Treating periodontitis through non-surgical periodontal therapy (NSPT) may improve glycemic control in type-2 Diabetes Mellitus (T2DM) patients. However, the evidence to maintain this improvement beyond four months is insufficient. Hence, this trial was conducted to assess clinical efficacy of NSPT on glycemic control in T2DM patients. METHODS: This three-arm randomized controlled trial recruited 150 known T2DM participants (35-65 years), suffering from moderate to severe periodontitis, having HbA1c level ≥ 6.5% at baseline. Participants were followed up at 3 and 6 months. Intervention for test group-1 included scaling and root planing (SRP) with metronidazole (MET) and oral hygiene instructions (OHI). Test group-2 was intervened with SRP + OHI and control group with OHI only. Stata v. 14 was used to observe inter and intragroup mean changes in glycemic [glycated hemoglobin (HbA1c), fasting blood glucose (FBG)] and periodontal variables [bleeding on probing (BOP), periodontal pocket depth (PPD), clinical attachment loss (CAL)] using ANOVA and RMANOVA. Proportion of change in outcome variable (HbA1c) was assessed between treatment groups using chi-square test. Change was considered significant at p-value ≤ 0.05. RESULTS: A significant reduction was observed in BOP, PPD, CAL, HbA1c and FBG over time [p < 0.05]. Significant reductions were observed in same variables in both test groups in comparison to control arm [p < 0.05]. No change between the two test groups was observed [p > 0.05]. CONCLUSION: Scaling and root planing improves glycemic control of T2DM patients independently of the use of MET. Therefore, SRP after every 6 months may be suggested and included as a part of overall diabetes management for patients suffering from T2DM. Clinical trial registration NCT 03,343,366 [Date of Registration: 17/11/2017].

Evaluation of HbA1c in type-2 diabetes mellitus patients with periodontitis: preliminary findings of three-arm clinical trial.

OBJECTIVE: To assess a relationship and predict changes in glycaemic control due to chronic periodontitis in type-2 diabetic patients. METHODS: Chronic periodontitis (CP) of a cross-section of 118 patients (age ?32 years) was determined using bleeding on probing (BOP), periodontal pocket depth (PPD) and clinical attachment loss (CAL). Their HbA1c, fasting blood glucose (FBG), fasting serum insulin (FSI) and homeostasis assessment model of insulin resistance (HOMA-IR) levels were also tested. Stata 11.0 was used to assess correlation between periodontal and glycaemic measures. Univariate analysis followed by multiple regression analysis through stepwise forward selection process was used to explore significant variables that may predict change in HbA1c. Multi-collinearity and heteroskedasticity were assessed at p-value > 0.05. RESULTS: Results of participants (n=95) showed significantly positive correlations (r) between HbA1c and BOP [r = 0.34, p-value = 0.002], PPD [r = 0.36, p-value = 0.003] and CAL [r=0.42, p-value = 0.002]. However, FBG and HOMA-IR were not found correlated with any of the periodontal measures; except CAL with FBG [r=0.27, p-value=0.02]. In addition to healthy controlled diet, cultural background, education and FBG, CAL was found significant [coef. = 0.746, p-value = 0.001, CI = 0.339, 1.153] to predict change in HbA1c in the final model [R2 = 0.549, p-value < 0.001] with no multicollinearity [mean VIF =1.30] and heteroskedasticity [chi 2 =0.02, p-value= 0.878] in fi n al model. CONCLUSIONS: Increased CAL is estimated to increase HbA1c level by 0.75% in T2DM patients after controlling other factors. It is suggested that periodontal prophylactic management may be planned with an aim to reduce HbA1c. CLINICAL TRIAL REGISTRATION NO: NCT03343366.

Presentations and Outcomes of Thyroid Storm.

The aim of this study is to describe the characteristics and outcome of thyroid storm patients presenting at two tertiary care centres of Karachi, i.e. at Dow University of Health Sciences; and Liaquat National Hospital, Karachi, from December 2018 to May 2019. All patients between 18-70 years of age, who were admitted with thyroid storm and fulfilled the Burch- Wartofsky criteria, were inducted. Demographics including age, gender, clinical presentations, systemic symptoms, clinical examination of the thyroid and laboratory findings were reviewed from the file records to identify factors associated with mortality using the available data. Overall, five (62.5%) out of eight patients were female. The mean age was 43 ±1.67 years. Infections were the most common comorbid condition followed by cardiovascular and gastrointestinal diseases. The in-hospital mortality rate was 87.5% (n=07).

Sero-negative celiac disease with dermatitis herpetiformes: a case report.

INTRODUCTION: We report a case of sero-negative celiac disease in Pakistan. CASE PRESENTATION: A 20-year-old female presented with papulovesicular rash for 15 years, diarrhea for 8 years, spasms of hands and twitching of face for 4-5 months. She had mild anemia, low vitamin-D3 and serum calcium. On exclusion of other causes of malabsorption, anti-tissue transglutaminase antibodies (immunoglobulin-A & immunoglobulin-G), anti-endomysial antibodies, total immunoglobulin-A levels and skin biopsy were performed, which were normal. Intestinal biopsy revealed subtotal villous atrophy. Patient was prescribed gluten-free diet, to which she responded with alleviation of symptoms. CONCLUSION: Negative serology should not rule out celiac disease; intestinal biopsy should be performed if there is strong clinical suspicion.