Relationship of sociodemographic factors with serum levels of vitamin D in a healthy population of Pakistan

Background: High prevalence of vitamin D deficiency has been reported from Pakistan. Association of sociodemographic factors with vitamin D status has received little attention in this region. Therefore, we embarked on investigating the relationship of sociodemographic factors with vitamin D levels in a healthy Pakistani population. Venous blood from 226 healthy participants [age range 19-69 years] was collected and analyzed for serum concentrations of 25[OH] vitamin D [25[OH]D] and other related biomarkers. Demographic characteristics of the study participants were collected. Vitamin D deficiency [25[OH]D levels less than 20 ng/ml] was found to be 75% in this cohort. Gender, sunlight exposure and monthly household income emerged as predictors of hypovitaminosis D. Mean serum 25[OH]D levels in the groups with monthly household income less than Pakistani Rupees [PKR] 20,000, between PKR 20,000-50,000 and above PKR 50,000 were found to be 11.0+/-7.5, 13.9+/-9.6 and16.9+/-11.7 ng/ml, respectively. Using logistic regression the odds of having vitamin D deficiency was 3.22 [95% CI, 1.65-6.28] in the group with household income less than PKR 50,000 per month compared to the group with household income more than PKR 50,000 per month when the model was adjusted for gender and exposure to sunlight. There is an association between household income and hypovitaminosis D in a healthy Pakistani population

Comparison of diagnostic accuracy of Glycated Hemoglobin [HBA1C] and 2-hour post Glucose for Diabetes using American Diabetic Association [ADA] cut offs in Pakistani population

Objectives: To determine median HbA1c level in patients screened for DM and compare the diagnostic accuracy of HbA1c with the currently recommended ADA cut off, using 2 hours [h] plasma glucose [2-h PG] post 75 grams oral glucose tolerance test [OGTT] as gold standard

Study Design: Cross sectional study

Place and Duration of Study: Aga Khan University Hospital Karachi, from Jul 2014 to Nov 2015

Patients and Methods: Consecutive subjects screened by OGTT for diabetes mellitus [DM] were included. Blood sample for plasma glucose and HbA1c were analyzed on ADVIA 1800

Results: Total 146 subjects were included with median age 45 [IQR 54.2-35] years; 53 percent [n=77] being females. Median HbA1c of the study subjects was 6 percent [IQR 6.6-5.6]. Positive correlation was observed between age and HbA1c [5.7 percent [IQR 6.2-5.3] <40 y, 6.2 percent [IQR 6.8-5.8] in >40 y subjects; r 0.34, p=0.000]. Males had higher HbA1c than females [6.1 percent [IQR 6.8-5.7] years. 5.9 percent [IQR 6.4-5.4]; r 0.17, p=0.036]. HbA1c levels were significantly different amongst the different ethnic groups residing in Pakistan [p-value<0.03]. HbA1c was positively correlated with FPG [r=0.59, p-value<0.001] and 2-h PG [r=0.56, p-value<0.001]. Sensitivity, specificity, PPV, NPV for HbA1c at cutoff of 6.5 percent in diagnosing diabetes mellitus [DM] were 70 percent, 89 percent, 72 percent and 80 percent respectively

Conclusion: High median HbA1c levels is noted in our subjects. At cut off level of HbA1c >/=6.5 percent, 70 percent of subjects with DM were diagnosed using ADA criteria of 2-h PG for diabetes as gold standard. Ethnic differences were also observed in levels of HbA1c. There is a need to define cut off for our population

Lack of association of statin use with vitamin D levels in a hospital based population of type 2 diabetes mellitus patients

Objective: To investigate the relationship of statins [drug given to reduce serum levels of LDL-cholesterol] on vitamin D levels of Pakistani type 2 diabetes mellitus [DM] patients in a hospital in Karachi

Methods: In a cross-sectional survey, 312 consecutive patients with type 2 DM [219 males and 93 females, age 22-70 years] were recruited with informed consent. A questionnaire was administered to find out whether they were statin users or non-users. Serum was analyzed for concentrations of 25[OH] vitamin D [25[OH]D] and other related biomarkers such as serum cholesterol, triglycerides, HDL-cholesterol, LDLcholesterol, phosphate and calcium using kit methods. Multiple Linear Regression was used to evaluate association of statin use with serum levels of vitamin D while adjusting for related covariates including duration of statin use, duration of type 2 DM and smoking

Results: Mean concentrations of serum cholesterol, and LDL-cholesterol were lower among statin users compared to statin non-users [P < 0.01], while HDL-cholesterol levels were higher [P<0.01]. No relationship was observed between statin use and serum levels of vitamin D [P=0.768], when adjusted for age, gender, BMI, duration of type 2 DM, smoking, serum cholesterol and LDL-cholesterol. The adjusted regression coefficient [beta] and standard error [SE[beta]] for statin use duration were 0.012 [0.042], when serum levels of vitamin D was taken as an outcome

Conclusion: Lack of association was found between statin use and vitamin D levels in a hospital-based population of Pakistani patients with type 2 DM

Pituitary tuberculoma

Tuberculosis rarely involves the hypothalamo-pituitary region and constitutes only 1% of the lesions involving the sellar and/or suprasellar region. Coleman and Meredith first reported pituitary tuberculosis in 1940, and only a handful of cases have been reported ever since. It may manifest as a chiasmal syndrome due to compression of the optic chiasm or as hypopituitarism due to pituitary destruction. It has a characteristic radiological appearance and can mimic a pituitary adenoma. Diagnostic procedures, such as trans-sphenoidal biopsy, are crucial for accurate diagnosis. We report a case of a 32-year male, who presented with complaints of headache and decreased visual acuity for the past 6 months. Eye examination revealed bitemporal hemianopsia. Brain MRI scan showed a mass in the sella with features suggestive of pituitary adenoma. Transcranial resection of the mass was performed; histopathology of the excised mass proved it to be a pituitary tuberculoma

Microalbuminuria in type-2 diabetes mellitus; the tip of iceberg of diabetic complications

Objective: To determine the prevalence of microalbuminuria and its association with hypertension and other diabetic complications among Type-2 diabetic patients attending at Aga Khan University Hospital Karachi

Methods: 1280 Type-2 diabetes patients who visited the outpatient department of Aga Khan University Hospital from September 2014 to August 2016 were included in the study. Microalbuminuria was diagnosed if spot urinary microalbumin excretion was confirmed to be more than 20mg/l. Hypertension was diagnosed if BP >140/90 or already on antihypertensive medications. Other demographic, clinical and laboratory data were also recorded

Results: Microalbuminuria was diagnosed in 404[31.56%] patients and among these albuminuric patients 335[82.9%] had hypertension. They were also dyslipidemic, having raised triglyceride levels, lower HDL levels, with more prevalence of background diabetic retinopathy and peripheral neuropathy. They also showed higher HbA1C levels and longer duration of diabetes

Conclusion: The prevalence of the microalbuminuria in our patients with Type-2 diabetes is 31.56% and is not only an early sign of diabetic nephropathy but also a host of other diabetic complications and should be dealt early with strict control of their hyperglycemia and hypertension to help prevent the future complications

prospective study of altered inflammatory response and its clinical outcome following laparoscopic and open cholecystectomy

Background: Inflammatory response following surgical trauma has long been a matter of study. Results, however, have been varied. We sought to assess changes in the levels of proinflammatory and anti-inflammatory cytokines in patients undergoing laparoscopic and open cholecystectomy and their impact on the clinical outcome of patients concerning the postoperative pain score

Methods:The study involved 90 cholecystectomies [55 laparoscopic and 35 open] for chronic cholecystitis. Blood samples were collected 2 hours preoperatively and at 4 and 24 hours post surgery. Sera were evaluated for the levels of interleukin-1beta, interleukin-10, and tumor necrosis factor-alpha. The independent sample t-test was used to compare the means of a variable between the 2 groups. Statistical analysis was done using SPSS, version 17

Results: The rise in the levels of interleukin-1beta, interleukin-10, and tumor necrosis factor-alpha was significantly more in the open cholecystectomy group at 4 hours [P<0.00]. At the 24[th] postoperative hour, the levels of all 3 cytokines were also higher in the open cholecystectomy group [P<0.001 for interleukin-1beta, P=0.185 for interleukin-10, and P<0.001 for tumor necrosis factor-alpha]. At the 4[th] postoperative hour, the patients in the laparoscopic cholecystectomy group had a significantly lower pain score [P<0.001] than the open group

Conclusion: Both laparoscopic and open cholecystectomy procedures altered the inflammatory milieu of our patients in the postoperative period. Inflammation caused by the laparoscopic procedure was significantly less. More research is needed to target specific inflammatory and anti-inflammatory cytokines to reduce surgical stress and improve patient outcomes

Male hypogonadism at a tertiary care hospital in Karachi, Pakistan

Male hypogonadism is defined as 'inadequate gonadal function, manifested by deficiency in gametogenesis and/or secretion of gonadal hormones'. Signs and symptoms of hypogonadism depend primarily on the age of onset. It can be classified according to the site primarily involved: the gonads, the hypothalamus, or the pituitary gland. The objective this study was to determine the presentation and aetiology of male hypogonadism seen in a tertiary care hospital. This cross-sectional study was conducted at Endocrine Clinics, Aga Khan University Hospital Karachi. Data of male patients with hypogonadism who attended clinics during January 2009 to August 2011 were reviewed. All male patients with clinical and biochemical evidence of hypogonadism were included in the study. Patients with Diabetes Mellitus, Metabolic Syndrome, Andropause, AIDS, Chronic Renal Failure, and Cirrhosis were excluded. Mean +/- SD were computed for quantitative variables. Frequency and percentages were computed for qualitative variables. Aetiology of male hypogonadism was categorised as primary and secondary hypogonadism. A total of 85 patients with male hypogonadism attended the endocrine clinic. Mean age of patients was 25 +/- 10 years. Clinical presentations were small genitalia [65%], absent secondary sexual characteristics [53%], not attained puberty [47%], infertility [53%], erectile dysfunction [41%] and loss of libido [29%]. Seventy-three [86%] patients had hypogonadotrophic hypogonadism [secondary hypogonadism] and 12 [14%] patients had hypergonadotrophic hypogonadism [primary hypogonadism]. Among the patients with hypogonadotrophic hypogonadism 38 had idiopathic hypogonadotrophic hypogonadsim, 7 had pituitary adenoma, 6 had empty sella syndrome, 3 had Kallman's syndrome, and 1 patient had haemosiderosis due to thalassaemia major; 18 patients did not undergo brain imaging. Small genitalia, absent secondary sexual characteristics and infertility were the main presenting features of hypogonad men. Majority of patients had hypogonadotrophic hypogonadsim.

Suppression of Mycobacterium tuberculosis induced reactive oxygen species and tumor necrosis factor-alpha activity in human monocytes of systemic lupus erythematosus patients by reduced glutathione

The etiology and pathogenesis of systemic lupus erythematosus remains unknown, evidence exists for the involvement of mycobacterial antigen. This study is aimed to determine the effect of Mycobacterium tuberculosis on clinical course of SLE patients and the role of ROS and TNF-alpha in the pathogenesis of tuberculosis associated SLE patients. This study was done on 100 patients divided into SLE group [n=30] TB group [n=30], SLE-TB group [n=30] and control group [n=10]. All patients underwent clinical, biochemical and immunological evaluation by employing techniques such as SDS-PAGE, direct binding and competition ELISA, PBMC and cell culture. Fever, arthritis, skin rash, photosensitivity were more common in both SLE and SLE-TB group Reduced glutathione showed amelioration of ROS and TNF-alpa, induced action, which in turn, subsequently suppressed the immune-bindings observed in monocytes of TB and SLE patients cultured without glutathione. Data shows that SLE patients are more susceptible to developing Mycobacterium tuberculosis, as ROS and TNF-alpha in SLE patients could activate the replication of mycobacterial Ag85B [30 kDa] after bacilli infection

Remission of Grave's disease after oral anti-thyroid drug treatment

To evaluate remission rate of anti-thyroid drug treatment in patients with Grave's disease, and to study the factors associated with remission. A cross sectional study. The Endocrine Department of the Aga Khan University Hospital, Karachi from 1999 to 2000. Seventy four patients of Grave's disease were recruited who were prescribed medical treatment. Grave's disease was diagnosed in the presence of clinical and biochemical hyperthyroidism along with anti-microsomal [AMA] and anti-thyroglobulin antibodies [ATA] and thyroid scan. These patients were prescribed oral anti-thyroid drugs using titration regime and followed at 3, 6, 12 and 18 months. Patients were categorized into two groups: "remission group" and "treatment failure group" and results were compared using a chi-square test, t-test and logistic regression model with significance at p < 0.05. A majority of the patients were females [62.6%, n=46]. During the follow-up period of 18 months, 41.9% patients went into remission. Univariate analysis showed that the initial free T4 level was significantly different [p < 0.05] in patients in remission and treatment failure groups. Multivariate analysis showed only initial free T4 level was a significant predictor of outcome. Positive AMA patients [n=27] had higher treatment failure [odds ratio: 2.55: 95%, CI 0.69 - 9:31], although the difference was not statistically significant [p = 0.13]. Remission rates with oral anti-thyroid agents is markedly high. Patients should be offered alternate treatment options to those who do not enter remission during a period of 12-18 months of treatment, those who develop relapse, and those who have aggressive disease on initial presentation

Hyponatraemia: etiology, management and outcome

To determine the etiology of hyponatraemia, the treatment instituted and the outcome of treatment in a tertiary care hospital setting. Case series. The Aga Khan University Hospital, Karachi, between January and June 2004. Case records of 220 patients admitted to the medical service were identified through computerized hospital patients' data. All patients >/= 15 years with a sodium level on admission of 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. 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

Static pulmonary nodules from thyroid malignancy

Papillary carcinoma of thyroid tends to be indolent. This is an unusual case of papillary carcinoma of thyroid with asymptomatic pulmonary metastasis for more than a decade, finally presenting with mild respiratory symptoms in a 21-year-old female. Fine needle aspiration and cytology [FNA-C] of a nodule in the lungs revealed features consistent with a papillary carcinoma of thyroid. Confirmed on thyroidectomy specimen. She subsequently received Iodine-131 [1[131]]. A follow-up radio-iodide scan, 48 hours after, revealed diffuse uptake within the lung parenchyma. With static nodular shadowing on radiograph, a metastatic origin, in particular that of the thyroid, should be considered. I[131] scintigraphy can help support the diagnosis of carcinoma of thyroid

Fine needle aspiration cytology of thyroid nodule; diagnostic accuracy and pitfalls

To evaluate the utility of FNAC in patients with Thyroid Nodule. Records of all patients treated surgically for thyroid nodule[s] at Aga Khan University Hospital from January 2000 to December 2004 were reviewed. The patients who had pre operative FNAC as first line of the evaluation and the final post operative histopathology report available were included in the study. 125 patients [90 female 35 male] had thyroid surgery. The cytological diagnosis was made according to following categories: Benign, Follicular lesion, Malignant and Inadequate sampling. Among 63 [Benign cases], 57 were benign and 6 turned out to be malignant. Among 44 cases from [Follicular group], 31 were benign and 13 were malignant. Out of 15 patients from [Malignant] group, 14 were malignant and 1 was benign. Among three patients from the [Inadequate sampling group], 2 turned out to be benign and one was malignant. The overall results showed a sensitivity of 98%, specificity of 70%, and positive predictive value of 91%, negative predictive value of 93% and diagnostic accuracy of 91%. We conclude that FNAC is an invaluable and minimally invasive procedure for pre operative assessment of patients with a thyroid nodule in our setting as well. FNAC has high sensitivity in picking up malignancy in thyroid and also has high diagnostic accuracy in the evaluation of thyroid nodules

Cervical spine tuberculosis

We present a case that showed extensive tuberculous cervical, first thoracic and fifth lumbar vertebrae involvement. The involvement was non-contiguous with relative sparing of the inter-vertebral discs and involvement of posterior element. Diagnosis was made on histology. Patient received anti-tuberculosis treatment and showed remarkable response