A 5-structured visits multidisciplinary clinical care approach to optimize the care of patients with type 2 diabetes: a pilot study.

Introduction: Multidisciplinary coordinated care has been associated with improvement of diabetes care. Aim and methods: This is a retrospective cohort analysis aimed to assess the effect of application of the five-structured visits Multi-disciplinary Clinical Care Approach (FMCA) on each of T2DM control, complications and comorbidities. The patients' records were assessed for one year of regular diabetes care followed with a year after implementation of FMCA for patients attending the diabetes clinic at Zulekha hospital. The patients were divided according to HbA1c (cutoff 7%) at the end of the FMCA year of follow-up into a group of controlled and another group of uncontrolled diabetes designated CDM and UCDM, respectively. Results: 49% of patients were males and the mean age was 44.22 years. HbA1c levels, LDL and urinary albumin/creatinine ratio (UACR) showed a marked decrease among the patients after implementation of FMCA (P = 0.02, P = 0.04, P = 0.003, respectively). Compared with an increase in the atherosclerotic cardiovascular risk score (ASCVD) during the regular period, exposure to FMCA significantly decreased the cardiovascular risk score (0.17%, 11.41%, P = 0.001, P = 0.001, respectively). A self-management score was significantly higher in CDM patients. After a multivariate regression analysis of factors affecting DM control, we detected that baseline HbA1c, UACR, self-management score and hospital admission rate were the most important factors to predict diabetes control. Conclusion: The implementation of FMCA has shown a significant improvement in clinical and humanistic aspects of individuals with T2DM with a better outcome, more control and less complications.

Renal function changes in patients with subclinical hyperthyroidism: a novel postulated mechanism.

BACKGROUND: Subclinical hyperthyroidism (SCH) is found to be associated with renal dysfunction. Hyperthyroidism is a well-known cause of secondary systolic hypertension. However, the effect of SCH on the kidney and its vasculature is still unknown. AIM: To assess the presence of renal function changes and renal vasodysfunction in SCH patients and their relation to hypertension. METHODS: The study included 321 patients with SCH and 80 healthy matched controls. Laboratory investigations included thyroid function tests, anti-TSH receptor antibody (TRAb), creatinine, estimated glomerular filtration rate (eGFR), serum osmolarity (S. Osmol), urine osmolarity (U. Osmol), Fractional Excretion of Sodium (FeNa), Fractional Excretion of Potassium (FeK), copeptin (CPP), and aldosterone/renin ratio (ARR). Ultrasound for the thyroid gland, echocardiography, total peripheral resistance (TPR), flow-mediated dilatation (FMD), and Renal Arterial distensibility (RAD) was also done. RESULTS: Serum creatinine was significantly lower while eGFR was significantly higher in SCH patients compared to euthyroid subjects (mean 0.59 ± 0.11 mg/dl Vs mean 0.8 ± 0.1 mg/dl, p = 0.001 and mean 128.28 ± 14.69 ml/min/1.73m2 Vs mean 100.49 ± 14.9 ml/min/1.73m2, p = 0.013, respectively). The TPR and FMD showed a significant decrease in SCH group compared to controls (mean 975.85 ± 159.33 mmHg.min/L Vs mean 1120.24 ± 135.15 mmHg.min/L, p = 0.045 and mean 7.03 ± 4.02% Vs mean 13.48 ± 4.57%, p = 0.003, respectively). RAD was significantly higher in hypertensive SCH patients compared to normotensive SCH patients (mean 17.82 ± 2.46 mmHg Vs mean 11.98 ± 3.21 mmHg, p = 0.001). CONCLUSION: SCH patients showed vascular resistance reduction. Alterations in thyroid hormones and blood pressure could be the driving mechanisms for the change in renal functions in patients with SCH.

Azathioprine as an adjuvant therapy in severe Graves' disease: a randomized controlled open-label clinical trial.

Introduction: Azathioprine (AZA) interferes with the activation of T and B lymphocytes, which are the main cells involved in the pathogenesis of Graves' disease (GD). The aim of this study was to investigate the effectiveness of AZA as an adjuvant therapy to antithyroid drugs (ATDs) for moderate and severe GD. In addition, we conducted an incremental cost-effectiveness analysis of AZA to determine its cost-effectiveness. Methods: We conducted a randomized, open-label, and parallel-group clinical trial. We randomized untreated hyperthyroid patients with severe GD into three groups. All patients received 45-mg carbimazole (CM) as the starting dose and propranolol 40-120 mg daily. The first group (AZA1) received an additional 1 mg/kg/day AZA, the second group (AZA2) received an additional 2 mg/kg/day AZA, and the third group (control group) received only CM and propranolol. We measured thyroid-stimulating hormone (TSH) and TSH-receptor antibody (TRAb) levels at baseline and every 3 months, while free triiodothyronine (FT3) and free thyroxine (FT4) levels were measured at the time of diagnosis, 1 month after initiation of therapy, and every 3 months thereafter until 2 years after remission. Thyroid volume (TV) was assessed by ultrasound at baseline and 1 year after remission. Results: A total of 270 patients were included in this trial. By the end of follow-up, there was higher remission rate in the AZA1 and AZA2 groups compared with controls (87.5% and 87.5% vs. 33.4%, p = 0.002). Throughout the course of follow-up, FT3, FT4, TSH, and TRAb were significantly different between the AZA groups and the control group, but there was no significant difference regarding TV. The decline in the concentrations of FT4, FT3, and TRAb was significantly faster in the AZA2 group than in the AZA1 group. The relapse rate during the 12-month follow-up was insignificantly higher in the control group than in either the AZA1 or AZA2 group (10, 4.4, and 4.4%, p = 0.05, respectively). The median relapse time was 18 months for the control group and 24 months for the AZA1 and AZA2 groups. The incremental cost-effectiveness ratio for the AZA group compared with the conventional group was 27,220.4 Egyptian pounds per remission reduction for patients using AZA as an adjuvant for ATDs. Conclusion: AZA could be a novel, affordable, cost-effective, and safe drug offering hope for patients with GD to achieve early and long-lasting medical remission. Trial registry: The trial is registered at the Pan African Clinical Trial Registry (Registration number: PACTR201912487382180).

COVID-19 treatment: A potential cause of acute pancreatitis.

Remdesivir can precipitate fatal acute necrotizing pancreatitis especially in patients who previously suffer from hypertriglyceridemia.

A Community Pharmacy-Based Intervention in the Matrix of Type 2 Diabetes Mellitus Outcomes (CPBI-T2DM): A Cluster Randomized Controlled Trial.

INTRODUCTION: Egypt has the ninth highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in community involvement in DM management. AIM OF THE STUDY: The aim of the study was to evaluate the tailored diabetes care model (DCM) implementation in Alexandria governorate by community pharmacy-based intervention (CPBI) from a clinical, humanistic, and economic aspect. METHODS: This is a 6-month period cross-over cluster randomized control trial conducted in Alexandria. Ten clusters owing 10 community pharmacies (CPs) recruited 100 health insurance-deprived T2DM patients with >7% HbA1c in 6-months. The study was divided into 2 phases (3 months for each period) with a 1-month washout period in between. After CPs training on DCM, the interventional group received pictorial training for 45 minutes in first visit, and 15 minutes in weekly visits, whereas the control group patients received the usual care (UC). At baseline and end of each phase (3 months), patients had clinical and physical activity assessments, filled all forms of study questionnaire (knowledge, self-management, satisfaction, and adherence) and did all laboratory investigations (Fasting Blood Glucose [FBG]), HbA1c, protein-creatinine clearance (PCR), creatine clearance (GFR), and lipid profile. RESULTS: There was no significant difference in the basal systolic and diastolic blood pressure between patients in the CBPI and UC groups, but the CBPI had significantly decreased the mean SBP and DBP by (P = .008, .040, respectively). Also, significant waist circumference and BMI reductions (-5.82 cm and -1.86 kg/m2, P = .001) were observed in the CBPI. The CBPI patients achieved a greater reduction in FBG and HbA1C than the UC patients (102 mg/dL and 1.9%, respectively P < .001). Also, significant reductions in total cholesterol, LDL, and triglyceride (-6.4, -15.4, and -6.3 mg/dL respectively, P = .001) were achieved in the CBPI group. No significant differences were found in HDL, GFR, and PCR. Moreover, significant improvements of behavior, score of knowledge, self-management, satisfaction, and adherence were observed in CBPI patients. After multivariate analysis, HbA1C readings were significantly influenced by baseline HbA1C and eating habits. The cost saving for CPBI was -1581 LE per 1% HbA1c reduction. CONCLUSION: This is the first study in Egypt that illustrated the positive impact of pictorial DCM delivered by CPBI collaborative care on clinical, humanistic, laboratory, and economic outcomes to local T2DM patients.

Thyroid disease and covid-19 infection: Case series.

Early and frequent evaluation of thyroid profile in COVID-19 infected patients is crucial as it will influence thyroid disease sequelae and management in those patients; moreover, it will facilitate setting an appropriate management plan.

A hidden cause of infertility in hypothyroid patients.

Methylene tetrahydrofolate reductase (MTHFR) gene mutations could be the cause of infertility in hypothyroid patients. Hence, it is worthy to screen for MTHFR gene mutations in infertile hypothyroid females and their partners if infertility persists after optimizing thyroid function.

Cross-Cultural Reliability of an Arabic Version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale in Arab Patients with Diabetes mellitus.

INTRODUCTION: Arab nations have the second highest diabetes mellitus (DM) prevalence in the world. There is a growing interest in self-management programs that emphasize patient's central role in managing type 2 DM. AIM OF THE STUDY: To validate an Arabic version of the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEM6S) among Arab type 2 DM patients and to explore factors associated with self-efficacy measured with the SEM6S. METHODS: Cross-sectional study on 302 Arab patients with T2DM of three different nationalities (Egyptian, Saudi, Kuwaiti).The SEM6S was translated using forward-backward method, and its reliability was determined by calculating Cronbach's alpha. A regression model was used to examine variables associated with self-efficacy in Arab patients with T2DM. RESULTS: Questionnaire was successfully translated without language or content-related problem. The mean age of participants was 47.71±14.7 years with equally represented sexes. The mean total score of the SEM6S was 5.99±1.86. The scale psychometric properties was reproducible (ICC=0.61-0.71) with good reliability (Cronbach's alpha=0.79). Statistically significant increase in self-efficacy was observed in patients <30 years, uncomplicated DM, DM with hypertension, and in patients who had physical activity > 60min per day. Also, a bimodal increase in self-efficacy was detected in patients with DM<5 years and 10.1-15 years. After regression analysis, physical activity was significantly positively correlated with self-efficacy (ß=0.8, P=0.01), and duration of diabetes was significantly negatively correlated with self-efficacy (ß = -0.23, P=0.03). CONCLUSION: Arabic SEM6S is acceptable, reliable and repeatable metric for self-efficacy.

Induction of remission in autoimmune polyglandular syndrome type three (APS III): An old drug with new perspectives.

The autoimmune polyglandular syndrome is a sequential chain of autoimmune events. Whenever diagnosed, the clinician's target should be induction of remission and if possible hindering its progression especially if associated with refractory vitiligo, resistant Grave's, or unexplained hyperglycemia in T1DM. Azathioprine could be used for induction of remission in autoimmune polyglandular syndrome type three especially with vitiligo and autoimmune thyroiditis.