Prevalence of metabolic syndrome and its association with CT-based central adiposity measures: a cross-sectional study at a tertiary care hospital in Pakistan.

OBJECTIVES: To assess the prevalence of metabolic syndrome (MS) and association of central obesity measures such as body mass index (BMI), visceral fat adiposity (VFA) and superficial fat adiposity (SFA) with MS, diabetes (DM) and hypertension (HTN). DESIGN: Cross-sectional study design. SETTING: Tertiary care hospital in Pakistan. PARTICIPANTS: 165 participants. There were 124 male participants and 41 female participants of Pakistani population. All participants above 18 years, who had unenhanced CT abdomen examination and relevant blood workup, were included. Patients with a known clinical history of coronary artery disease, HTN and DM as well as pregnant patients were excluded. INTERVENTIONS: VFA and SFA were estimated, at the level of the umbilicus. Data of BMI, MS, DM and HTN were extracted from patient files. Data for MS, DM and HTN were recorded as binary variables. OUTCOME MEASURES: The primary outcome measures were the prevalence of MS and the association of MS, DM and HTN with gender, VFA, SFA and BMI. P value of <0.05 was taken as significant with CI of 95%. RESULTS: The prevalence of MS was 29.7%. There was a significant association of MS, DM and HTN with VFA, SFA and BMI. In gender-based analysis 48.7% of the female participants had MS. In subset analysis, 47% of male subjects in the third tertile of VFA revealed significant association with MS (p value <0.05) while only 32.7% of subjects in the obesity category of BMI had MS. SFA revealed a significant association with DM only (p value <0.5). CONCLUSION: In conclusion, VFA shows a significant association with MS, DM and HTN. Considering these results, further studies with a larger sample size are warranted to generate gender-based cut-offs for VFA for obesity screening purposes.

Mid-axillary transversus abdominis plane block and stress response after abdominal hysterectomy: A randomised controlled placebo trial.

BACKGROUND: The hormonal response to surgical trauma can have detrimental effects on patients. Transversus abdominis plane (TAP) block, which can improve analgesia after total abdominal hysterectomy (TAH) might attenuate the peri-operative stress response. OBJECTIVE: To evaluate the ability of the TAP block to reduce stress response, opioid consumption and pain following TAH and multimodal analgesia. DESIGN: Randomised, placebo-controlled double-blind study. SETTING: The current study was conducted at a university hospital from July 2016 to September 2017. PATIENTS: Fifty patients scheduled for TAH were included. Anaesthesia and postoperative analgesia were standardised. INTERVENTION: After induction of anaesthesia, patients were allocated into two groups: ultrasound-guided bilateral mid-axillary TAP block with 20 ml of bupivacaine 0.25% (Group T) or 0.9% saline (Group C). MAIN OUTCOME MEASURES: Levels of free serum cortisol, metanephrine and normetanephrine at 60 min and 6, 12 and 24 h after surgical incision. Pain scores and opioid consumption during the first 24 h after surgery. RESULTS: There was no statistically significant difference between the median [IQR] peri-operative levels of stress hormones and pain scores between groups. Compared with baseline value 9.90 [4.2 to 23.1], free serum median cortisol levels were significantly high at 6 h in Group T, 23.6 [10.1 to 42.9] P = 0.015 and Group C 23.6 [9.9 to 46.3] P = 0.014. Only Group C showed significant elevation from the baseline median levels of plasma metanephrine at 60 min, 52.8 [33.4 to 193.2] P = 0.001, 6 h, 92.70 [2.4 to 202.6] P = 0.005 and normetanephrine at 60 min 83.44 [28.98 to 114.86] P = 0.004, 6 h 78.62 [36.6 to 162.31] P = 0.0005 and 24 h 80.96 [8.6 to 110.5] P = 0.025. Mean ±â€ŠSD opioid consumption was similar in both groups: 39.60 ±â€Š14.87 in Group T vs. 43.68 ±â€Š14.93 in Group C (P = 0.338). CONCLUSION: Mid-axillary TAP block does not improve stress response and analgesia in patients undergoing TAH receiving multimodal analgesia. TRAIL REGISTRATION: ClinicalTrial.gov identifier: NCT03443271.

Lifestyle changes and glycemic control in type 1 diabetes mellitus: a trial protocol with factorial design approach.

BACKGROUND: Type 1 diabetes (T1D) has been increasing globally over the past three decades. Self-monitoring of blood glucose is a challenge in both developed as well as developing countries. Self-management guidelines include maintaining logbooks for blood glucose, physical activity, and dietary intake that affect glycated hemoglobin (HbA1c) and a multitude of life-threatening acute complications. Innovative, cost-effective interventions along with beneficial lifestyle modifications can improve home-based self-monitoring of blood glucose in T1D patients. The overall objective of this study is to evaluate the relationship between maintaining log books for blood glucose levels, reinforcement by e-messages, and/or daily step count and changes in HbA1c. METHODS/DESIGN: A randomized controlled trial will enroll participants aged 15 years and above in four groups. Each group of 30 participants will be working with a newly designed standard log book for documenting their blood glucose. The first group will be entirely on routine clinical care, the second group will be on routine care and will receive an additional e-device for recording step count (fit bit), the third group will receive routine care and daily motivational e-messages to maintain the log book, and the fourth group along with routine care will receive an e-device for measuring step count (fit bit) and e-messages about maintaining the log book. Patients will be enrolled from pediatric and endocrine clinics of a tertiary care hospital in Karachi. All groups will be followed up for a period of 6 months to evaluate outcomes. Log book data will be obtained every 3 months electronically or during a patient's clinic visit. HbA1c as a main outcome will be measured at baseline and will be evaluated twice every 3 months. A baseline questionnaire will determine the socio-demographic, nutritional, and physical activity profile of patients. Clinical information for T1D and other co-morbidities for age of onset, duration, complications, hospitalizations, habits for managing T1D, and other lifestyle characteristics will be ascertained. Behavioral modifications for maintaining daily log books as a routine, following e-messages alone, fit bit alone, or e-messages plus using fit bit will be assessed for changes in HbA1c using a generalized estimated equation. DISCUSSION: The proposed interventions will help identify whether maintaining log books for blood glucose, motivational e-messages, and/or daily step count will reduce HbA1c levels. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03864991. March 6, 2019.

Anthropometric measurements in children having transfusion-dependent beta thalassemia.

OBJECTIVES: The aim of this study was to determine the anthropometric measurements in transfusion-dependent ß-thalassemia children in Pakistan. The secondary aim was to correlate serum ferritin with the physical growth. METHODS: We enrolled 367 children (aged 5-17 years) with transfusion-dependent beta-thalassemia major in the study. Anthropometric measurements, serum ferritin levels, and pre-transfusion hemoglobin levels were measured. Serum ferritin was correlated with the height z-score for age. RESULTS: Laboratory evaluation showed that patients had significantly low mean pre-transfusion hemoglobin of 7.66 ±â€…1.34 g/dl (range 2.5-10.5) and high median (Q3-Q1) serum ferritin of 5012 ng/ml (6829-3532). The median (Q3-Q1) height-for-age z-score of children was low at -2.69 and (-1.46 to -3.80) and 65.4% children had stunted growth (height for age z-score <-2). There was a significant negative correlation between height for age z-score and serum ferritin levels (p < 0.000). Stunting of growth began early during 5-10 years of age but increased markedly with the progress of time. CONCLUSIONS: The study showed that children with beta thalassemia major had delayed physical growth possibly secondary to iron overload. Effective and early iron chelation is needed for preventing growth failure in transfusion-dependent beta thalassemia.

Demographic characteristics, presentations and treatment outcome of patients with prolactinoma.

BACKGROUND: Prolactinomas are the most common type of functional pituitary tumours. The objective of this study was to determine demographic profile of patients with prolactinomas, and to compare the outcomes in patients treated with Cabergoline versus those receiving Bromocriptine treatment. METHODS: This descriptive study was conducted at Endocrinology Section, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan. We reviewed the medical record of 68 patients with prolactinoma. Data about demographic characteristics, clinical presentation and treatment were entered on a pre-designed pro forma. RESULTS: Out of the total 68 patients, 36.8% were males and 63.2% were females, with a mean age of 34±10.7 years. The most frequent presenting complaint amongst the patients was of headache, present in 57.4% patients. Galactorrhea, amenorrhea and infertility were next highest reported symptoms. Results of the tumour size on initial MRI showed macroprolactinomas 52.9% (36), microprolactinomas in 33.8% (23), and giant prolactinomas in 13.3 % (9) patients. Decreasing trend of prolactin levels were also seen on follow up visits at 9 months and 12 months. Tumour size was decreased in 48.53% (33) patients and lesion completely disappeared in 16.18% (11) patients after 6 months of treatment and also almost similar trend in tumour size change was seen after one year. There was no significant difference between the two drugs in bringing prolactin to, normal range at each follow up duration. CONCLUSION: Most of the prolactinoma patients were females and the common the most frequent presenting complaint was headache. The decreasing trend of serum prolactin and tumour size reduction in patients was noted, suggesting the beneficial impact of medical therapy as it is the first line treatment modality in these patients.

Prevalence and significance of vitamin D deficiency and insufficiency among apparently healthy adults.

OBJECTIVE: This study aims to determine the prevalence and significance of vitamin D deficiency and insufficiency among apparently healthy adults. DESIGN AND METHODS: A total of 123 subjects, 56.9% males and 43.1% females, were recruited from a tertiary care hospital in Karachi, Pakistan. Questionnaires were administered to gather demographics; height, weight, and blood samples were also taken. For staging serum 25OHD, the cutoff values ≤50 nmol/L and 50.1-74.9 nmol/L were defined as deficiency and insufficiency, respectively. RESULTS: The mean vitamin D level in the study subjects was 41.1±9.6 nmol/L. Of them, 90% had low serum 25OHD levels: 69.9% were deficient and 21.1% had insufficient levels of 25OHD. There was a significant negative correlation between serum 25OHD and iPTH levels. CONCLUSION: The high prevalence of vitamin D deficiency and insufficiency showed that a high proportion of apparently healthy adults are at risk of developing musculoskeletal and other chronic diseases. Serum iPTH and serum 25OHD levels are better markers of this deficiency as compared to other markers.

Vitamin D Deficiency in ambulatory patients.

OBJECTIVE: To determine the frequency of subclinical vitamin D deficiency in an ambulatory care setting. METHODS: This was an observational study which measured 25 vitamin D levels in medical clinic patients. Patients with chronic renal failure, known osteomalacia and rickets were excluded. A total of 119 patients were evaluated. They were divided in three diagnostic categories based on their serum 25 vitamin D levels. Those with levels below 8 ng/ml were categorized to have severe deficiency, levels between 8 - 20 ng/ml as moderate deficiency and levels of 21-35 mg/ml as mild deficiency. RESULTS: Of 119 patients, 92% had vitamin D deficiency. Their mean age was 44.3 +/- 18.3 years, with female to male ratio of 5:1. Sixty two percent (62%) had severe, 24% moderate and 8% had mild deficiency. Nearly half of all these patients (including those with severe deficiency) were asymptomatic. Whereas a low serum calcium, elevated phosphate and elevated alkaline phosphatase were reflective of severe deficiency. It was only an elevated iPTH that correlated with mild to moderate deficiency. CONCLUSION: Subclinical vitamin D deficiency is extensive in the adult ambulatory care patients. Serum calcium, phosphate and alkaline phosphatase are poor markers of moderate to mild deficiency. A serum 25 vitamin D level and an iPTH are better biofunctional markers of this deficiency.