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.

Relationship of serum inducible and endothelial nitric oxide synthase with exercise in healthy adult males and patients with type 2 diabetes mellitus.

OBJECTIVE: The importance of physical activities in the control of diabetes mellitus disorder is well known but its correlation with endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in diabetic patients needs to be assessed. The aim of the study is to examine inducible and endothelial nitric oxide synthase in healthy adult male patients with type 2 diabetes mellitus (T2DM) in relation to exercise. PATIENTS AND METHODS: This is a cross-sectional study that has been performed in the Department of Physiology, King Saud University, Riyadh, Saudi Arabia. Subjects were divided into Group 1: control (n=79), and Group 2: T2DM (n=85). Each group was subdivided into three subcategories: sedentary, moderate activity, and active subjects. Serum nitric oxide (NO), iNOS, eNOS, high sensitivity C-reactive protein (hs-CRP), nitrates, and nitrites, were compared between different groups. RESULTS: We observed significant differences in iNOS in diabetic patients compared to the control [29.1 (2.8) vs. 22.4 (1.4), p=0.050] with a significant decrease in eNOS when compared to the control group [79.5 (4.8) vs. 101.8 (5.7), p=0.003]. In the control group, eNOS showed significant differences (increase) between subgroups; sedentary, moderate, and active control subjects [77.4 (9.2), 114.7 (9.3), and 105.6 (9.5), p=0.026]. It also showed insignificant differences between subgroups in iNOS [23.4 (2.5), 24.2 (2.2), and 20.4 (2.4), p=0.520]. In addition, hsCRP showed a decrease with exercise but with no statistically significant difference between the groups [4.0 (0.5), 3.3 (0.3), and 2.9 (0.4), p=0.271]. In the diabetic patients' group, a significant difference (decrease) between subgroups in iNOS [43.5 (4.8), 20.8 (3.9), and 19.8 (4.6), p<0.001] and hsCRP [5.7 (0.5), 3.8 (0.4), and 3.6 (0.5), p=0.006] was detected. In addition, eNOS showed a decrease with exercise but with no statistically significant difference between groups [82.9 (7.8), 74.6 (7.9), and 81.7 (10.2), p=0.741]. CONCLUSIONS: Patients with T2DM have shown significantly low eNOS and high iNOS levels. Furthermore, regular exercise can significantly decrease iNOS in patients with T2DM. Therefore, the importance of exercise for diabetic patients has to be emphasized to prevent long-term complications related to diabetes mellitus.

Predictive value of arm circumference (AC) and arm muscle circumference (AMC) with cardiovascular risk in healthy and diabetic males.

OBJECTIVE: The predictive value of body simplified indices needs to be evaluated properly for cardiovascular risk. This study aimed to assess and compare the relative relationship of arm circumference (AC), arm muscle circumference (AMC), body mass index (BMI), and waist-hip ratio (WHR) with Ultra-Sensitive C-Reactive Protein (US-CRP) in healthy male subjects and with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS: We performed the study at the department of Physiology, College of Medicine & King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia. It was a cross-sectional study with 93 healthy male subjects and 112 type 2 diabetic male patients who underwent body composition analysis by BIA and fasting venous blood samples were collected. US-CRP and body composition were determined for all subjects. RESULTS: US-CRP is correlated positively with AC (0.378) and BMI (0.394) more than AMC (0.282) and WHR (0.253) which have lower correlation both in control and DM group. BCM has the lowest correlation with US-CRP (0.105). The association between US-CRP and AC, AMC, Body Fat Percent (BFP), and body fat mass (BFM) are statistically significant except for BFP in DM group. In control group, AC is noticed to be a better predictor for US-CRP, with area under curve (AUC) 64.2% (p=0.019), WHR with AUC 72.6% (p<0.001), and BMI with AUC 65.4% (p=0.011) but AMC is not a good predictor in control group with AUC 57.5% (p=0.213). In DM group, AC is noticed to be a better predictor for US-CRP, with AUC 71.5% (p<0.001), WHR with AUC 67.4% (p=0.004), BMI with AUC 70.9% (p=0.001), and AMC with AUC 65.2% (p=0.011). CONCLUSIONS: Simplified muscle mass body indices like AC and AMC have significant predictive value for assessing cardiovascular risk in both healthy population and patients with T2DM. Therefore, AC could be used as a future predictor for cardiovascular disease in healthy and DM patients. Further investigations are needed to confirm its applicability.

Health hazards related to using masks and/or personal protective equipment among physicians working in public hospitals in Dhaka: A cross-sectional study.

BACKGROUND: Wearing masks or personal protective equipment (PPE) has become an integral part of the occupational life of physicians due to the coronavirus disease 2019 (COVID-19) pandemic. Most physicians have been developing various health hazards related to the use of different protective gears. This study aimed to determine the burden and spectrum of various health hazards associated with using masks or PPE and their associated risk factors. METHODS: This cross-sectional survey was conducted in Dhaka Medical College from March 01-May 30, 2021, among physicians from different public hospitals in Dhaka, Bangladesh. We analyzed the responses of 506 physicians who completed case record forms through Google forms or hard copies. FINDINGS: The mean (SD) age of the respondents was 35.4 [7.7], and 69.4% were men. Approximately 40% were using full PPE, and 55% were using N-95 masks. A total of 489 (96.6%) patients experienced at least one health hazard. The reported severe health hazards were syncope, severe dyspnea, severe chest pain, and anaphylaxis. Headache, dizziness, mood irritation, chest pain, excessive sweating, panic attack, and permanent facial disfigurement were the minor health hazards reported. Extended periods of work in the COVID-19-unit, reuse of masks, diabetes, obesity, and mental stress were risk factors for dyspnea. The risk factors for headaches were female sex, diabetes, and previous primary headaches. Furthermore, female sex and reusing masks for an extended period (> 6 h) were risk factors for facial disfigurement. The risk factors for excessive sweating were female sex and additional evening office practice for an extended period. CONCLUSIONS: Healthcare workers experienced several occupational hazards after using masks and PPE. Therefore, an appropriate policy is required to reduce such risks.

Serum inducible and endothelial nitric oxide synthase in coronary artery disease patients with Type 2 Diabetes mellitus.

OBJECTIVE: Coronary artery disease (CAD) is a well-known cause of morbidity and mortality in type 2 diabetes mellitus (T2DM). The role of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in T2DM patients in relation to CAD is not well understood. We examined serum inducible and endothelial nitric oxide synthase activities in patients with T2DM in relation to the presence of coronary artery disease. PATIENTS AND METHODS: The present study was conducted in the Department of Physiology, King Saud University, Riyadh, Saudi Arabia. Subjects were grouped into control (Group A, n=87), T2DM without CAD (Group B, n=70), and T2DM patients with CAD (Group C, n=49). The selection of T2DM subjects was according to the American Diabetes Association (ADA). Serum iNOS, eNOS, hsCRP, nitrates and nitrites along with lipid profile were compared between different groups. Spearman's correlation and ROC analysis were also performed. RESULTS: Serum eNOS levels were significantly high in the control group (112.38±47.16 U/ml) than in DM without CAD (81.43±49.91 U/ml) and DM with CAD (84.80±43.32 U/ml, p<.001). Serum iNOS levels were significantly higher in DM with CAD (42.87±28.83 U/ml) compared to both control (22.08±11.77 U/ml) and DM without CAD (16.24±12.30 U/ml, p<.001). Additionally, the differences in nitrite and NO were not significant between the three groups (34.06±24.75, 33.02±21.50, 38.83±24.34 uM, p = .384), and (56.51±36.78, 49.89±28.83 vs. 55.77±30.34 uM, p=.416) respectively. ROC curve analysis revealed a sensitivity and specificity of 73.5% and 68.6% of iNOS level at a cutoff point of 21.1 U/ml to predict CAD in T2DM patients. The ROC analysis for iNOS, eNOS, and hs-CRP were .782 (p<.001), .574 (p=.170), and .726 (p<.001), respectively. CONCLUSIONS: Patients with T2DM have significantly higher levels of serum iNOS and lower levels of eNOS. However, iNOS levels were significantly higher in T2DM patients with concomitant CAD. Moreover, iNOS activity positively correlated with glycemic control and hsCRP. Therefore, iNOS could be an emerging future marker for CAD in T2DM patients and its antagonists could be useful in the management of these patients.

Echocardiographic Assessment of Left Atrial Systolic Function after Percutaneous Mitral Balloon Valvuloplasty Using Tissue Doppler Imaging.

Mitral stenosis (MS) affects left atrial (LA) function as a result of hemodynamic and myocardial factors that causes significant symptoms and complications. Conventional echocardiographic methods have been practicing to see the improvement of left atrial function after successful percutaneous mitral balloon valvuloplasty (PMBV). Introduction of tissue doppler imaging allows direct and non-invasive measurement of myocardial velocities. The aim of the study was to evaluate LA functions after PMBV using colour tissue doppler imaging. This cross sectional study was performed in Cardiology department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from March 2014 to February 2015. Forty six (46) patients (28 females, mean age: 28.96±5.78 years) presenting with mitral valve stenosis who fulfilled the indications for PMBV were included in the study. Within 24 hours before PMBV, all the patients underwent colour tissue doppler study in addition to routine conventional echocardiographic examinations. Late diastolic velocities (A') measured at the septal and lateral annuli were recorded. All the measurements were repeated 24 hours after PMBV. The PMBV was done using the Inoue technique. After PMBV mitral valve areas (MVA) were significantly increased. Maximum and mean gradients, LA diameter, LA area, LA volume, systolic pulmonary arterial pressure and mean LA pressures were decreased while septal and lateral A' were significantly (p<0.001) increased. Lateral and septal A' velocities were correlated with MVA and inversely related to LA pressure measured invasively during PMBV. Tissue doppler velocities illustrated improvement of left atrial systolic function after PMBV in relation to decreased mean left atrial pressure and increased mitral valve area. Therefore, tissue doppler Imaging is a useful tool to detect improvement of left atrial systolic function after PMBV in patients with mitral stenosis.

Management of encapsulating peritoneal sclerosis: a guideline on optimal and uniform treatment.

Encapsulating peritoneal sclerosis (EPS) represents a rare complication of long-term peritoneal dialysis (PD). It is characterised by diffuse peritoneal membrane fibrosis, progressive intestinal encapsulation and the clinical spectrum of intestinal obstruction. The pathogenesis is as yet not well understood but includes inflammation, angiogenesis and fibrosis. The current diagnosis of EPS lacks specificity and relies on clinical, radiographic or macroscopic evaluation. There is no general agreement on managing EPS although accumulating clinical data suggest drug treatment (steroids, tamoxifen), surgery (enterolysis) or a combination of both. Here, we provide a short overview on the current knowledge of EPS, with a focus on treatment. Moreover, we present a diagnostic and a therapeutic algorithm for EPS based on the best available published data and our combined experience.

Role of ETT to diagnose coronary artery disease.

The purpose of the study to predict the coronary arterial disease by exercise treadmill scoring system and to see the correlation of angiographic extent of coronary artery disease by high treadmill score in our country. The present prospective study carried out in the department of cardiology, Bangabandhu Sheikh Mujib Medical University, University Cardiac Centre during the period of January 2006 to July 2006. Based on inclusion and exclusion criteria a total of 80 patient of chronic stable angina or chest pain evaluation having positive ETT who were admitted in university cardiac centre in Bangabandhu Sheikh Mujib Medical University and underwent coronary angiogram within one month were the study population. Among 80 subjects 60(75%) were male and 20(25%) were female and male: female ratio 3:1 Mean age of male subject 51.37±9.08 years and mean age of female subjects were 43.75±7.67 years. Three quarter of the subject had the history of typical anginal pain followed by 21.3% atypical and 3.8% pain of non-anginal origin. All the risk factors like, dyslipidemia (90%), HTN (68.8%) past smoker (45%), current smoker (32.5%), diabetes (36.3%), family history of coronary artery disease (25%) and sudden death of first degree relatives (8.8%); dyslipidemia was the highest percentage. Among 80 subjects more than one third 35% (28) of the subjects were observed to be normal by angiogram, 28.8% (23) had SVD, 16.3% (13) DVD and 20% (16) TVD. Approximately 70% of the significant stenosis was predicted as having high probability of 30.8% as intermediate probability and none as low probability with exercise test scores. Multi-vessel coronary artery disease were predicted by high probability exercise test score 82.8%. Thus high probability score needs urgent coronary angiogram.

Posttransplantation encapsulating peritoneal sclerosis contributes significantly to mortality after kidney transplantation.

Encapsulating peritoneal sclerosis (EPS) is a severe complication of peritoneal dialysis (PD) and may present after kidney transplantation, a condition known as posttransplantation EPS. The prevalence and impact of posttransplantation EPS on survival after kidney transplantation is unknown. From January 1, 1996 until July 1, 2007, 1241 PD patients were transplanted. Thirty-eight cases of posttransplantation EPS (3%) were identified from the Dutch multicenter EPS study. In EPS patients the mean pretransplant dialysis duration was longer than in the controls (71.4 ± 37.5 months vs. 34.7 ± 25.5, p < 0.0001). The majority of EPS cases were observed within the first 2 years after transplantation, but some cases appeared many years after transplantation. Two hundred and one (16.2%) patients died after transplantation, of which 17 were EPS patients. After infection (23.9%), cardiovascular disease (21.9%) and malignancy (10.9%), EPS (8.5%) was the fourth known cause of death after transplantation. Kaplan-Meier analysis showed a significant decreased survival for transplanted patients with posttransplantation EPS compared to transplanted patients without EPS. In conclusion, posttransplantation EPS is rare but carries a high mortality. A prolonged clinical vigilance and a high index of suspicion for the diagnosis are warranted, specifically in PD patients with a relatively long cumulative pretransplant duration of PD.

Congenital aneurysm of the left atrium.

Isolated left atrial (LA) aneurysm is a rare condition, whereas LA aneurysm secondary to other causes is a fairly common condition. A case of large left atrial aneurysm presented with features of heart failure with cardiac arrhythmia and an abnormal cardiac silhouette on chest X-ray. A 14 years old girl presented with palpitation at rest, shortness of breath, productive cough and bilateral leg swelling for last 8 months. There was no history of chest pain, hemoptysis, syncope, prolonged fever, and rheumatic fever. She was mildly anemic, had raised JVP and mild bilateral pedal edema. There was left parasternal heave, soft S1, loud P2 and a pansystolic murmur of grade 3/6 over mitral area radiating to the left axilla. ECG showed multifocal atrial tachycardia (MAT), chest X-ray showed cardiomegaly with bulging of the left heart border with upper lobe diversion. Echo-Doppler study showed hugely dilated LA (115 mm in diameter), dilated left ventricle, Grade-2+ mitral regurgitation (MR), mild tricuspid regurgitation (TR) and mild pulmonary hypertension with normal appearing mitral, aortic and tricuspid and pulmonary valves. The patient was diagnosed as a case of congenital aneurysm of LA.