Cutaneous manifestations of diabetes mellitus type 2: prevalence and association with glycemic control

Objective: To determine the frequency and pattern of skin disorders in patients with type 2 diabetes mellitus and their association with glycemic control in our diabetics

Methods: This descriptive, cross-sectional study was conducted at departments of Medicine and Dermatology, Sir Syed College of Medical Sciences and Hospital, Karachi from 1[st] January to 30[th] June 2014. Adult patients belonging to both genders having diabetes mellitus type 2 with cutaneous manifestations were included. After taking the informed consent, demographic details, duration of diabetes, mode of treatment for diabetes, types of footwear, foot care and glycemic profile were documented

Results: In 203patients [41% male and 59% female], mean age was 50 +/- 11 years and mean duration of diabetes 8.5 +/- 7 years. Mean HbA1c was 8.6 +/- 1.5 with 68% patients having unsatisfactory glycemic control. Most frequently observed skin disease was bacterial infections [26%], followed by fungal infections [22%], acanthosis nigricans [20%], diabetic foot [16%], nail changes [16%], acrochordons [10%], diabetic dermopathy [9%], necrobiosis lipoidica [9%], viral infections [8%] pruritus [8%] and xanthelasma [8%]. There was significant association of unsatisfactory glycemic control with bacterial infections [p = 0.037] and fungal infections [p = 0.023]. Females especially had a higher frequency of association with acanthosis nigricans [p = 0.030]

Conclusion: Patients with type 2 DM have high frequency of infections especially bacterial and fungal. Other manifestations like acanthosis nigricans and diabetic foot are comparatively less common

Alzheimer and vascular dementia in the elderly patients

Objectives: To find out the frequency of Alzheimer's and Vascular dementia in the elderly patients

Methods:This cross sectional descriptive study was conducted in Department of Medicine, Ziauddin Hospital Karachi from 1[st] October 2013 to 31[st] March 2014. Patients with symptoms of dementia for more than 6 months duration, and Mini Mental State Examination score <24 were included in this study. Patients who fell in category of dementia were assessed for duration of symptoms. Patients underwent CT scan of brain. Patients with generalized atrophy of brain on CT scanning of brain were labeled as Alzheimer's dementia, while patients with ischemic or hemorrhagic stroke on CT scan of brain were labeled as vascular dementia

Results:Four hundred twenty two patients were included in this study. There were 232 [54.98 %] male and 190 [45.02 %] were female. The mean age +/- SD of the patients was 72.58+/-5.34 years [95%CI: 72.07 to 73.09], similarly average duration of symptoms was 10.14+/-2.85 months. About 18.96% of patients were illiterate, 32.23% were matric, 28.44% were intermediate and 20.33% were graduate and post graduate. Hypertension and diabetes were the commonest co-morbid i.e. 81.3% and 73.7%, hyperlipedimia and smoking were 38.2% and 45% respectively. Frequency of Alzheimer's disease and vascular dementia in the elderly was observed in 3.79% [16/422] and 2.61% [11/422] cases

Conclusion:A good number of patients, 27 out of 422, in this hospital based study were suffering from Alzheimer's disease and vascular dementia. Early detection and prompt treatment can reduce the burden of the disease in our population

Diabetic foot ulcers in a tertiary care hospital; risk factors, associations and grades of presentation

Objective: To determine the various risk factors for diabetic foot ulcers and study their associations. To study the grades of diabetic foot ulcers at presentation

Study design: Comparative descriptive study

Setting: Department of Medicine; PIMS Hospital, Islamabad

Study duration: 15[th] July 2012 to 15[th] Jan 2013

Material and methods: 254 cases were selected after informed consent. Study group [A] comprises of 127 cases of type 2 diabetes with diabetic foot ulcer and control group [B] comprises of 127 cases of age and gender matched type 2 diabetics without foot ulcers. Patients having ulcer for >/=4 weeks, who underwent debridement, having serious systemic illness, type I diabetics and non-diabetic patients presenting with foot ulcer were excluded. Age, gender, duration of diabetes, duration of ulcer, glycemic control, presence of neuropathy and vascular disease were documented. Grading and Staging of ulcer was done according to New University of Texas Diabetic Wound Classification. Various risk factors were compared between the two groups. Data analyzed via SPSS version 17 with significant p-value < 0.05

Results: Among 254 cases [68.5 % males and 31.5 % females]; mean age was 55.9 +/- 10.79 [group A] versus 51.9 +/- 11.4 [group B]. Mean duration of diabetes was longer in group A [9.36 +/- 6.05 years] vs. group B [7.39 +/- 4.89 years] [p = 0.016]. Glycemic control was poor in group A [64.6 %] vs. group B [52 %] [p = 0.04]. There was significantly more peripheral vascular disease in group A [47.2 %] vs. group B [29 %] [p = 0.005]. Sensory neuropathy was more in group A [94.5 %] vs. group B [39.4 %] [p < 0.0001]. Grade-I ulcer was present in 17.32 % cases, Grade-II in 37.79 % and Grade-III in 44.88 %

Conclusion: Neuropathy carries highest risk for diabetic foot ulcer, followed by peripheral vascular disease and poor glycemic control. Therefore diabetic patient must be educate about these risk factor, foot care and self-examination and to have regular screening by clinician. Appropriate glycemic control and timely medical and surgical intervention may reduce morbidity in diabetics

Diabetes knowledge in elderly type 2 diabetes mellitus patients and association with glycemic control

Background: With the increased life expectancy, there is rise in geriatric diabetic population. A knowledgeable diabetic in collaboration with physician can contribute to a successful diabetes management plan. Current study was conducted to determine the diabetes knowledge, its associations and risk factors in elderly type 2 diabetics

Methods: This descriptive cross sectional study was conducted at outdoor Medicine Dept. Rawal Institute of Health Sciences Islamabad over 8 months period from January to August 2015. Geriatric type 2 diabetics [>65 years] were included. Critically ill patients, having physical or mental limitation to answer the questionnaire were excluded. The demographic details, socioeconomic class, literacy level, duration of diabetes, other modes of therapy and glycemic control documented. Michigan Diabetes Knowledge Questionnaire [DKQ-24] was applied with outcome of diabetes knowledge as good, acceptable and poor. Data analyzed by SPSS version 17 with significant p-value < 0.05

Results: Among 163 diabetics [21.5% males and 78.5% females], mean age was 64.7+5.6 years and mean duration of diabetes 8.4+6.6 years. Diabetes knowledge was poor in 86[52.8%], acceptable in 37[22.7%] and good in 40[24.5%] diabetics. Poor diabetes knowledge was found to be associated with illiteracy, poverty, unsatisfactory glycemic control, practicing other modes of therapy and poor dietary control

Conclusion: The unsatisfactory diabetes knowledge in geriatric diabetic population needs to be addressed. Illiteracy and low socioeconomic class are the contributory factors in addition to advanced age. Imparting knowledge to geriatric group about diabetes and its complications, dietary advice supplemented by easy to interpret diet charts and literature may lead to empowerment of geriatric diabetics for better diabetic control and reduced diabetes related morbidity

Predictors of severity of dengue fever in tertiary care hospitals

Background: Dengue fever, an emerging public health issue in Pakistan bears considerable morbidity and mortality. This descriptive cross sectional study was conducted to analyze clinical, hematological and serological characteristics of dengue fever variants and to identify biomarkers that predict its severity

Methods: 105 dengue cases [>12 years] were selected after ethical approval from Rawal Institute of Health Sciences and Benazir Bhutto Hospital Rawalpindi over 6 months [July to Dec 2015]. Patients having pre-existing hematological disorder, liver disease, malaria and typhoid co-infection were excluded. Demographic data, clinical findings, hematological and serological profile documented. Patients were classified as classic dengue fever [DF], dengue hemorrhagic [DHF] and dengue shock syndrome [DSS]. Data analyzed via SPSS version 17

Results: Among 105 cases, there were 79[75%] males and 26[25%] females. Mean age was 30 +/-12.8 years and mean duration of symptoms 5 +/-2 days. Dengue fever was found in 75[75%], dengue hemorrhagic fever 24[23%] and dengue shock syndrome 2[2%]. Gender, mean age and duration of symptoms were comparable between DF, DHF and DSS. Common clinical features were fever [100%], headache [56%], muscle pain [43%], vomiting [43%], retro-orbital pain [23%], bleeding [12%] and hypotension [10%]. Thrombocytopenia, leukopenia and pancytopenia were frequent in DHF vs. DF. Dengue NS-1 antigen positive in 71[90%] of DF cases vs 16[57%] DHF and 1[50%] DSS. Dengue-IgM positive in 32[47%] DF vs. 19[79%] DHF and 2[100%] DSS. Dengue -IgG detected in 33[42%] DF vs. 17[71%] DHF and 1[50%] DSS. 101[96%] dengue cases were treated successfully and one case expired

Conclusion: Dengue-IgG and IgM are better predictive variables for dengue hemorrhagic fever as compared to NS-1 antigen that predicts classic dengue fever. Utilizing these predictive variables, imminent severe dengue may be identified and with vigilant monitoring, fluid resuscitation and pre-hand arrangement of blood products we may reduce complications and mortality in high risk cases

Plasmapheresis versus intravenous immunoglobulins in guillain barre syndrome, the therapeutic outcomes

To compare the therapeutic outcomes of plasmapheresis with intravenous immunoglobulins [IVIG] for Guillain Barre syndrome. Randomized controlled trial. Medicine department; PNS Shifa Hospital Karachi from Jan 2011 to Jun 2012. Adult patients admitted to internal medicine department with the diagnosis of Guillain Barre Syndrome [GBS] fulfilling the inclusion and exclusion criteria were included after taking ethical approval and informed consent. They were randomly assigned to plasmapheresis and IVIG treatment groups. Their presenting features, investigations and management plan were followed over 6 months duration. Hughes disability scale for Guillain Barre syndrome was documented and compared at admission, 4 weeks, 12 weeks and 6 months by non-parametric tests via SPSS version 17. Total 36 patients [31 males and 5 females] were included. Mean age was 37 +/- 15 [18-70] years, mean duration of symptoms 11.6 +/- 12.7 days. Plasmapheresis and IVIG groups were comparable with respect to age and gender [p>0.05]. Significant improvement of mean disability score was observed in each group from baseline score [p<0.0005]. At specified intervals, comparison between the two groups in terms of mean improvement in disability scores showed significant improvement at 4 weeks [p<0.05] in IVIG group as compared to plasmapheresis group; however on further observation at 12 weeks and 6 months, mean improvement was comparable between two groups with no significant difference [p>0.05]. There was no significant difference in need for assisted ventilation between two groups [p>0.05]. Variants of GBS observed were AIDP [50%], AMAN [31%] and AMSAN [19%]. Our study suggests that both plasmapheresis and intravenous immunoglobulins are useful and effective modes of treatment for Guillain Barre Syndrome. Significant short term improvement was observed in the IVIG group at 4 weeks of treatment; however no significant difference in therapeutic outcome observed between the two groups on further follow up of 6 months. Thus focusing the need of further large scale regional studies to analyze various factors contributing to this short term but significant improvement with IVIG treatment observed in this study

Newly Diagnosed Anemia in Admitted Diabetics, Frequency, Etiology and Associated Factors

Objective: To determine the frequency of newly-diagnosed anemia in diabetics admitted to the Internal Medicine Department and its etiology and contributing factors. Study Design: A cross-sectional, analytical study. Place and Duration of Study: Department of Internal Medicine, Sir Syed Trust Hospital and College of Medical Sciences, Karachi, from July 2011 to December 2012. Methodology: Adult diabetic patients first diagnosed as having anemia upon hospital admission during the specified duration were included. Patients with active bleed, acute renal impairment, critical illness, pregnancy and previously diagnosed anemia were excluded. Etiology and risk factors of anemia were determined in each case on the basis of history, clinical findings and relevant laboratory investigations i.e. complete blood picture, red cell indices, iron profile, renal function tests, urine and stool examination. Association of anemia was determined using chi-square and t-tests with p-value < 0.05 taken as significant. Results: One hundred and thirty patients [34 males and 96 females] were included. Mean age was 51 +/- 12.4 years, with mean BMI of 25.4 +/- 5.2 kg/m2, mean duration of diabetes of 7.6 +/- 5.5 years and mean glycated haemoglobin [HbA1c] 8.47 +/- 1.58%, with 75% diabetics having unsatisfactory glycemic control. Mean haemoglobin was 11.6 +/- 1.96 g/dl. Anemia was present in 63% diabetics [18 males and 64 females]. It was normocytic in 59.8%, microcytic in 37.8% and macrocytic in 2.4%. Chronic Kidney Disease [CKD] was present in 44%, iron deficiency in 23%, mixed etiology in 6%, vitamin B-12 deficiency in 2% and thalassemia minor in 1% cases. Statistically significant association of anemia was found with poor glycemic control [p=0.002], dietary restriction for red meat [p < 0.001], history of blood loss [p < 0.001], gastrointestinal disorders [p < 0.001], CKD [p < 0.001] and retinopathy [p=0.011]. Conclusion: Anemia in two out of every three diabetics in this study points to need for haematological screening in all diabetics presenting to healthcare facility. In addition to chronic kidney disease, dietary iron and vitamin deficiency, glycemic control, presence of CKD, retinopathy and gastrointestinal disorders need to be evaluated and rectified. Key Words: Anemia. Chronic kidney disease. Diabetes mellitus. Dietary iron. Glycemic control. Retinopathy. Vitamin B-12.

Obesity and hypertension in female medical students; frequency and risk factors

OBJECTIVE: To determine the frequency and risk factors of obesity and hypertension in female medical students

STUDY DESIGN: Descriptive cross sectional study

SETTING: Department of Medicine, Sir Syed College of Medical Sciences and Hospital Karachi

STUDY DURATION: 3 months [March 2014 to June 2014]

MATERIAL AND METHODS: Total 307 female medical students were included after ethical approval

Students with systemic illness, diabetes mellitus and taking corticosteroids were excluded

Demographic details obtained, followed by anthropometric measurements; height, weight, waist circumference and body mass index [BMI]. Students were classified as underweight, at risk, overweight, obesity grade I and obesity grade II as per WHO criteria for Asians. Blood pressure of each student was measured at two occasions. Outdoor activity time, screen time, sedentary time, dietary preferences, sleep hours and family history documented. Data analyzed via SPSS version 17 with significant p-value < 0.05

RESULTS: Among 307 students, obesity was found in 34% [25.4%obesity grade I and 8.8% obesity gradeII]. Hypertension was found in 4.88 %. There was significant association between hypertension and obesity [12 % obese hypertensiveversus 1.9 % non obese hypertensive students]

35 % students had higher waist circumference that was associated with hypertension. Excessive use of soft drinks, diet drinks, meat, dairy products, chocolates, oversleep on weekends and daily screen time >2 hours were found to be associated with obesity

CONCLUSION: Higher prevalence of obesity and obesity related hypertension in younger age group needs to be addressed. Those with obesity should be screened for the presence of hypertension at younger age. Waist circumference should be considered in addition to BMI while screening for obesity, and evaluation of its risk factors in Asians.Creating awareness and timely intervention in terms of dietary modification, adequate physical activity and sleep hours thus reducingthe screen time and sedentary time may help in controlling obesity and its complications among our young generation. Weight loss must be the first line of therapy in obesity related hypertension among younger obese population

Dermatological manifestations of obesity

To determine the frequency of various cutaneous manifestations in patients with obesity and correlate these skin changes with the grades of obesity. The study was conducted at Departments of Medicine and Dermatology, Sir Syed College of Medical Sciences and Hospital Karachi from 1[st] January 2014 till 30[th] June 2014. Patients belonging to both sexes and different age groups having body mass index [BMI] >/=25kg/m[2] with cutaneous manifestations of obesity were enrolled. Patients with skin changes secondary to other systemic illnesses, pregnancy and drugs were excluded. After an informed consent, demographic details, height and weight were documented. A clinical dermatological diagnosis was established after a detailed history and examination. Appropriate investigations were performed where required. 196 patients, 76 males [39%] and 120 females [61%] completed the study. Mean age was 43.6 +/- 10.8 years, age range being 19-70 years. Mean BMI 34 +/- 4.73 kg/m[2] [range 25-50], grade I obesity in 75 [38%] and grade II obesity in 121 [62%] cases. The most common finding observed was acanthosis nigricans [49%], followed by striae [17%], fungal infections [15%], acrochordons [12%], viral infections [11%], hirsutism [11%] and bacterial infections [7.5%]. Other less common associations included: xanthomas, corns, plantar hyperkeratosis and acne. Acanthosis nigricans and viral infections were significantly more among females; corn and callus among males. Obesity grade II was significantly associated with acanthosis nigricans, viral infections, hirsutism, striae and stasis dermatitis. Obesity is commonly associated with a wide range of dermatological manifestations like acanthosis nigricans, striae, hirsutism, skin infections. Other less common associations include: xanthomas, corns, plantar hyperkeratosis and acne

Newly diagnosed hepatitis-b and hepatitis-c during surgical pre-operative assessment of patients from lower socioeconomic class; frequency, risk factors and vaccination status

OBJECTIVE: To see the frequency of newly diagnosed Hepatitis-B and Hepatitis-C cases during pre-operative surgical assessment of patients from lower socioeconomic class and to study the possible risk factors

STUDY DESIGN: Descriptive Cross Sectional study

SETTING: Department of Surgery, Sir Syed College of Medical Sciences and Hospital, Karachi

STUDY DURATION: From July 2012 to July2013

MATERIAL AND METHODS: Total 107 patients [>18 years] of both genders from lower socioeconomic class planned for elective surgical procedure were included after ethical approval. Previously diagnosed cases of Hepatitis-B and C were excluded. After history and clinical examination, Hepatitis-B and Hepatitis-C serology was performed [ELIZA technique]. History of blood transfusion, previous dental or surgical procedures, intravenous injections, intravenous drug abuse, tattooing, piercing, circumcision, shaving by barbers, unprotected sex and Hepatitis-B vaccination status obtained. Data was analyzed by SPSS version 17

RESULTS: Among 107 cases [42% males and 58% females] with mean age 39+14 years, Hepatitis-B infection was present in 6[6%] cases, Hepatitis-C in 11[10%] and Hepatitis-B and C serology was negative in 90 [84%] cases. Frequency of Hepatitis-B was 3% [in males] versus 9% [in females]; Hepatitis-C 6.4% [in males] versus 15.5% [in females]. Among those with Hepatitis-B or C, history of previous surgical procedure present in 47% cases [vs. 21% in Hepatitis-B and C negative cases], dental procedure in 29.4% [vs. 7.7 %], intravenous injections in 94% [vs. 43%], intravenous drug abuse in 5.8% [vs. 0 %], blood transfusion in 35% [vs. 12%], tattooing in 0% [vs. 2%], unprotected sex in 5.8% [vs. 1%], piercing in 64.7% [vs. 39%], circumcision by barbers in 83.3%of males [vs. 80%], shaving by barbers in 66.6% of males [vs. 27%]. Hepatitis-B and C was found to be associated with history of blood transfusion, intravenous injections, dental procedures, shaving by barbers, piercing and intravenous drug abuse [p< 0.05]. Clinical stigmata of liver disease were present in 3% cases. Among all cases 9% were previously vaccinated for Hepatitis-B

CONCLUSION: Preoperative determination of Hepatitis viral markers is a good clinical practice to limit transmission from asymptomatic carriers and to diagnose new cases. Pakistan has high prevalence of Hepatitis-B and C and poverty and low literacy rate are the main determinants of its spread. Those who are negative for Hepatitis-B should be encouraged to get vaccinated

There is need for measures to create awareness about preventive measures and affective control of transmission of Hepatitis-B and C in community as well as at health care facilities

Hoffman syndrome; rare presentation of hypothyroidism

Hypothyroidism may present with various systemic manifestations including hypothyroid myopathy as a recognized feature. It is characterized by muscle weakness, pain, stiffness, and cramps along with elevated muscle enzymes and thyroid stimulating hormone levels.One of the rare presentations of hypothyroidism is Hoffman Syndrome characterized by myopathy along with muscle pseudohypertrophy and raised muscle enzymes. We report a case of Hoffman syndrome that showed significant clinical and biochemical response to thyroid hormone replacement

This case report highlights the clinical features, diagnostic approach and management of Hoffman syndrome. This signifies that early diagnosis and appropriate management improves outcome and prognosis. There have been few such cases reported worldwide and we report this rare case from Pakistan