The efficacy and safety of Emblica officinalis aqueous fruit extract among adult patients with dyslipidemia: A systematic review and meta-analysis

Background@#Flavonoids from Emblica officinalis effectively reduced serum and tissue lipid levels through their inhibitory effect on the hepatic β-hydroxy-β-methylglutaryl coenzyme A reductase activity. This study aimed to determine the efficacy and safety of E. officinalis extract in adults with dyslipidemia.@*Methods@#We searched the following electronic databases: MEDLINE (PubMed), MEDLINE (Ovid), Google Scholar, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science, and ClinicalTrials.gov from inception until January 31, 2022. Two reviewers independently screened the abstracts, reviewed full-text papers, and critically appraised the quality of included studies. Meta-analysis was performed using the random-effects model. Our primary outcomes were total cholesterol, LDL-C, serum triglycerides, and HDL-C levels, while secondary outcomes included adverse events.@*Results@#A total of four randomized trials (N = 227) were included in the final analysis. There were statistically significant decreases in total cholesterol levels (SMD = -21.23 mg/dL, 95% CI: -34.22, -8.25; P = 0.001) and LDL-C levels (SMD = -25.12 mg/dL, 95% CI: -40.24, -10.00; P = 0.001) and significant increase in HDL-C levels (SMD = 4.74 mg/dL, 95% CI: 0.40, 9.07; P = 0.03) after 12 weeks of intervention favoring the use of the Emblica extract over placebo. However, there were no statistically significant difference in the serum triglycerides levels following 12 weeks of treatment (SMD = -22.28 mg/dL, 95% CI: -53.33, 8.76; P = 0.16). There was high heterogeneity noted across all outcomes: total cholesterol (P = 0.01, I2 = 72%), LDL-C (P = 0.0004, I2 = 83%), HDL-C (P < 0.00001, I2 = 91%) and serum triglycerides (P < 0.00001, I2 = 93 %). The intervention was well tolerated and adverse events reported in the three of four studies were all mild: dyspepsia (7 events – treatment), mild diarrhea (3 events – placebo), fever (1 event – placebo), headache (1 event – placebo).@*Conclusion@#Compared to placebo, Emblica officinalis fruit extract resulted in lower total cholesterol and LDL-C levels and increased HDL-C levels but with no effect on serum triglyceride levels based on low certainty of evidence. Trials with a larger sample size that directly compare E. officinalis extract to statins, preferably local data, are needed to support its use in patients with dyslipidemia further.

The prevalence of metabolic syndrome among adult Filipinos with hypothyroidism: A retrospective cohort study

Background and Objective@#Dyslipidemia in hypothyroidism results from the effects of thyroid hormones on lipid metabolism. These, in combination with hypothyroidism-induced hemodynamic changes, are risk factors for cardiometabolic diseases. We determined the prevalence of metabolic syndrome (MS) among adult Filipinos with hypothyroidism and compared clinical and laboratory characteristics of those with versus without MS. @*Methods@#This is a retrospective study of 105 patients with biochemically confirmed hypothyroidism. A review of records obtained anthropometric measurements, blood pressure, fasting blood glucose, lipid profile, and thyroid hormones. Clinical and laboratory characteristics were then compared between MS and those without. Significant differences were determined by two-way ANOVA, while heterogeneity of categorical variables was determined by chi-square or Fisher exact test. All data analyses were performed using Stata version 17.0 with a significance level of p<0.05.@*Results@#The prevalence of MS is 36.19% (95%CI: 27.04%,46.15%). Body mass index (BMI) peaks at obese class I among those with MS. There is a significantly higher proportion of patients diagnosed to have diabetes (28.95% vs. 7.46%; p=0.003) and hypertension (52.63% vs. 14.93%; p<0.001) in the MS group. No significant differences were noted between groups regarding age, sex, etiology of hypothyroidism, blood pressure, fasting glucose, lipid profile, and thyroid hormone levels.@*Conclusion@#Our study showed that the prevalence of MS in adult Filipinos with hypothyroidism is increased at 36.19%. Only BMI, presence of diabetes, and hypertension were shown to be significantly higher. Emphasis must be placed on early screening among hypothyroid patients at high risk of developing MS. A prospective study using waist circumference and clinical and metabolic parameters is needed to validate these findings.

Exophytic and fungating papillary thyroid carcinoma: A rare and complex presentation of a well-differentiated malignancy

@#Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.

Critical Illness-Related Corticosteroid Insufficiency (CIRCI) among patients with refractory shock at a tertiary hospital: A look into clinical practices and patient outcomes

@#<p style="text-align: justify;"><strong>Introduction.</strong> A significant number of critically ill patients, as high as 60% among patients with septic shock, suffer from critical illness-related corticosteroid insufficiency (CIRCI), which refers to an inadequate corticosteroid response to the level of stress.</p><p style="text-align: justify;"><strong>Objectives.</strong> This study aimed to determine the strategies employed in managing patients with critical illness-related corticosteroid insufficiency and the outcomes of these patients at a tertiary hospital.</p><p style="text-align: justify;"><strong>Methods.</strong> This was a single-center, mixed-methods study which consisted of a review of charts of patients 19 years old and above admitted for shock or developed refractory hypotension from January 2017-December 2019, and key informant interviews and focus group discussion among clinicians who have experience in managing CIRCI.</p><p style="text-align: justify;"><strong>Results.</strong> A total number of 362 patient charts reviewed showed a relatively low rate of initiation of corticosteroids for patients with refractory shock, at just 28.57% of the entire population. After corticosteroids were initiated, patients were in shock for a median of just one day and the median blood pressure improved to 100/60 mm Hg. In this cohort, patients who were started on steroids had more severe illness, as measured by the Mortality Probability Model (MPM) score, which had a median of 43.65% for the group on steroids and just 25.0% for the non-steroid group (p ? 0.0001). Patients who were started on steroids had a statistically significant longer median days on a ventilator, 5 days vs. 3 days for the non-steroid group (p = 0.0297); longer median length of intensive care unit (ICU) stay, 8 days vs. 5 days for the non-steroid group (p = 0.0410), and a higher morbidity and mortality rate. The need for steroids, the presence of septic shock, and a higher MPM score were significant predictors of mortality.</p><p style="text-align: justify;">Discussions among clinicians revealed significant variability in practices in the management of CIRCI.</p><p style="text-align: justify;"><strong>Conclusion.</strong> The presence of clinical features of CIRCI is a poor prognostic factor. Timely recognition, work-up, and interventions to address CIRCI are paramount in critical care.</p>