Safety of sodium-glucose cotransporter 2 inhibitors (SGLT2i) during the month of Ramadan in patients with type 2 diabetes mellitus in Pakistani population-an observational study from a tertiary care center in Karachi.

BACKGROUND AND AIMS: Primary aim was to assess the safety of SGLT2-i in patients with Type 2 Diabetes Mellitus (T2D) in a real-life scenario during Ramadan by finding the frequency and severity of hypoglycemic/hyperglycemic events, dehydration, and Diabetic ketoacidosis (DKA). Secondary aim was to assess changes in glycated hemoglobin (HbA1c), weight and creatinine levels. METHODS: This prospective, observational, controlled cohort study was conducted at Aga Khan University Hospital, Karachi, Pakistan from March 15 to June 30, 2021. Participants were over 21 years of age, on stable doses of SGLT2-I, which was started at least 2 months before Ramadan. Endpoint assessments were done 1 month before and within 6 weeks after Ramadan. RESULTS: Of 102 participants enrolled, 82 completed the study. Most (52%) were males, with mean age 52.2 ± 9.5 years and average duration of T2D 11.2 ± 6.5 years. 63% were on Empagliflozin (mean dose; 14.8 ± 7.2 mg/day) whereas 37% were on Dapagliflozin (mean dose; 8.2 ± 2.7 mg/day). Six (7.3%) documented symptoms of hypoglycemia. However, no episode of severe hypoglycemia, hyperglycemia, dehydration, DKA, hospitalization or discontinuation of SGLT2i was reported. HbA1c changes were (7.7 ± 1.2% from 7.9 ± 2.3%, p 0.34), weight (78.4 ± 12.9 kgs from 78.9 ± 13.3, p 0.23) and eGFR (87.8 ± 27.9 from 94.3 ± 37.6, p < 0.001). The reasons of study participants drop outs were: six did not keep any fasts; four discontinued study participation for personal reasons; three were out of city and missed post Ramadan follow-up, two protocol violation and five could not be contacted for post-Ramadan follow up during the third wave of COVID-19. CONCLUSION: Results showed the safety of SGLT2i agents during Ramadan in the Pakistani population recommending it as a treatment option in adults with T2D, without any additional adverse events.

Functional pituitary gonadotroph adenoma in male patients: Case report.

Pituitary gonadotroph adenomas are common but very rarely do they secrete biologically active luteinizing hormone (LH) and follicle-stimulating hormone (FSH). There have been case studies reporting high sex hormones (testosterone/estrogen) in the presence of high or normal LH and FSH. Here we report two cases (with their consent) who presented with visual disturbance and headache at a tertiary care hospital (Aga Khan university hospital) Karachi, Pakistan. Brain imaging revealed a pituitary macroadenoma. Further workup was consistent with pituitary gonadotroph adenoma with high FSH (case 1) and normal LH/FSH (case 2) and elevated serum testosterone in both cases. Transsphenoidal resection was performed and the tissue sample histopathology confirmed pituitary adenoma. Postoperatively, improvement in hormonal profile was observed along with a resolution of visual disturbances and headaches. Thus, functional gonadotroph adenoma should be considered in the presence of elevated testosterone/estrogen and normal or elevated follicle-stimulating hormone (FSH)/ luteinizing hormone (LH). Early diagnosis leads to a better outcome.

Frequency of hashimoto thyroiditis in papillary thyroid cancer patients and its impact on their Outcome.

BACKGROUND: Hashimoto thyroiditis (HT) is an autoimmune disorder of thyroid gland and is the most common cause of hypothyroidism. Its association with thyroid lymphoma is well established but with papillary thyroid cancer (PTC), the studies have shown inconsistent results. METHODS: It is a retrospective review of papillary thyroid cancer patients and 213 participants were included for final analysis. They were divided in two groups, based on presence or absence of Hashimoto thyroiditis. We noted their demographic details, histopathological diagnosis, presence of thyroid autoantibodies, TNM staging, outcome and duration of follow up. RESULTS: The frequency of Hashimoto thyroiditis in papillary thyroid cancer patients was found to be 34.27% (73). In Hashimoto thyroiditis and PTC patients, more patients were in T1 and T2 stage, i.e., 27.4% and 38.4% as compared to PTC alone group, who had more patients with T3 and T4 disease 44.3% and 5% respectively. Although lymph node metastasis was more common in PTC with Hashimoto thyroiditis 56.2%, but distant metastasis was observed more in isolated PTC group 14.3%. Cure was observed in 75.3% and 47.1% in PTC patients with and without Hashimoto thyroiditis respectively. While 22.9% patients having isolated PTC had persistent disease as compared to 6.8% when PTC was accompanied with Hashimoto thyroiditis. CONCLUSIONS: The papillary thyroid cancer patient who had concomitant Hashimoto thyroiditis, had a less aggressive disease in terms of T stage and distant metastasis and they had a better outcome in terms of higher cure rate and less persistent disease as compared to the papillary thyroid cancer without Hashimoto thyroiditis.

Association between glycemic control and the outcome in hospitalized patients with COVID-19.

PURPOSE: Coronavirus disease 2019 (COVID-19) clinical outcome and disease severity affected by several factors; deterioration of glycemic control is one of them. Therefore, achieving optimum blood glucose parameters is hypothesized for better consequences of COVID-19. However, varying data supporting this hypothesis is available in literature. The intention of this study was to investigate the role of glycemic management on the prognosis of hospitalized COVID-19 patients with varying degrees of severity. METHODS: From April 2020 to January 2021, we carried this retrospective cohort in a clinical care facility in Pakistan. RESULTS: Mortality was lowest in patients with HbA1c of less than 7% (53 mmol/mol) (p < 0.001). Similarly, mortality was found lowest in patients with fasting blood glucose less than 126 mg/dl and random blood glucose less than 160 mg/dl (p < 0.001 in each). In contrast, need for admission in critical care was found highest in patients with HbA1c between 7 and 10% (53-86 mmol/mol) (p 0.002). However, participants with blood glucose levels during fasting greater than 200 mg/dl and random blood glucose levels greater than 250 mg/dl were found to have a greater need for invasive mechanical ventilation. Cox regression hazard showed no difference in risk of death and invasive mechanical ventilation based on previous glycemic control. CONCLUSION: Effective diabetic management is correlated with a considerably lower risk of mortality and invasive mechanical ventilation in COVID-19 cases.

Clinical outcomes of Sodium-glucose cotransporter-2 inhibitors in patients with Type 2 Diabetes Mellitus: An observational study from Pakistan.

OBJECTIVE: To determine the efficacy and safety of Sodium-glucose cotransporter-2 inhibitors (SGLT2i) use in the Pakistani population. METHODS: Retrospective review of initial 100 patients who were prescribed with any agent of the SGLT2i group from July 1, 2018, to January 2019 at Aga Khan University Hospital, Karachi. SGLT2i was offered to patients of above 18 years of age with inadequate glycemic control on existing antidiabetic agents. Changes in HbA1c, the Body Mass Index (BMI), serum creatinine, any decrease in the requirement of insulin and sulphonylurea dose along with any side effects reported by the patients on follow-up visits. RESULTS: Most study participants were females (56%) with the mean age of 52±10 years. Substantial changes were observed in the HbA1c (7.5±1.1%, 7.9±1.2% from 8.7±1.5%, p < 0.01), BMI (31.4±5.8, 31.8±5.8 from 32.4±5.9kg/m2, p < 0.01) and in creatinine (0.71±0.1, 0.75±0.1 from 0.79±0.1 mg/dl, p < 0.01) at three and six months of follow up visits. The reduction in insulin and sulphonylurea doses was also significant. Adverse drug events that led to drug discontinuation in 14 individuals were, Urinary tract infection (UTI) (seven patients), Genital infection (three patients), nausea +UTI, abdominal pain +UTI, mild Diabetic Ketoacidosis, and polyuria (one patient each). None reported Fournier's gangrene, limb amputation, or fracture. CONCLUSION: SGLT2i significantly improved glycemic control, BMI, and serum creatinine in the Pakistani population with a very low number of observed adverse events.

Mesenteric ischemia in COVID-19 patients: A review of current literature.

BACKGROUND: Coronavirus disease 2019 (COVID-19) virus has affected all the systems of the body, defying all impressions of it being a respiratory virus only. AIM: To see the association of mesenteric ischemia with COVID-19. METHODS: After initial screening and filtering of the titles on PubMed and Google Scholar, 124 articles were selected. Articles were read in full, and the references were skimmed for relevance. Twenty-six articles (case reports and case series) were found to eligible for inclusion. References of these 26 articles were checked for any additional cases. Two more publications were found, and a total of 28 articles (22 case reports and 6 case series) have been included for review in this manuscript. RESULTS: A total of 41 cases of acute mesenteric ischemia in COVID-19 patients have been reported in the literature since the outbreak of this pandemic. Most of them include patients with comorbidities. CONCLUSION: In conclusion, based on this literature review and precise published knowledge regarding acute mesenteric ischemia in patients with COVID-19, it is essential to understand its relevance in all patients with gastrointestinal symptoms. The threshold for the diagnostic investigations should also be kept low for the timely diagnosis and management of this disorder.

The Utility of Ultrasound in the Preoperative Localization of Primary Hyperparathyroidism: Insights from Pakistan.

Objective We aimed to evaluate and compare the diagnostic performance of ultrasound (US) and 99m-Tc sestamibi scintigraphy for the preoperative localization of primary hyperparathyroidism (PHPT). Methods This retrospective study was conducted at the Aga Khan University Hospital in Karachi, Pakistan, and comprised the data of patients with PHPT who underwent parathyroidectomy from 2008 to 2017. Preoperative US and 99m-Tc sestamibi scintigraphy findings were recorded and compared to surgical and histological findings, which were taken as a reference standard. Results The sensitivity of US in the preoperative localization of PHPT was 88.3%, positive predictive value (PPV) was 94.6%, and accuracy was 84.1%. The sensitivity of 99m-Tc sestamibi scintigraphy was 90.4%, PPV was 94.3%, and accuracy was 85.7%. Conclusion US neck is an efficient tool for the preoperative localization of PHPT, demonstrating a comparable diagnostic yield with 99m-Tc sestamibi, and can serve as a credible first-line imaging modality in a resource-constrained healthcare setup.

Primary Hyperparathyroidism: Experience from a Tertiary Care Centre in Pakistan.

OBJECTIVE: To study the clinical, biochemical and radiological features and management outcomes of patients with primary hyperparathyroidism. METHODS: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan and comprised data of patients with primary hyperparathyroidism from 2008 to 2017. RESULTS: Out of 103 patients, 83(80.6%) were female. Overall mean age was 59.3±16.2 years. Musculoskeletal manifestations were seen in 60(58.3%) patients and renal manifestations in 28(27.2%). Ostieits fibrosa cystica was found in 04(3.88%) patients. Overall, Ultrasound neck and sestamibi scan localized the lesion in 66 (64.1%) and 77 (76.2%) patients respectively. Among 79 patients who underwent surgery, 67 (84.8%) patients had an adenoma, 05 (6.3%) had hyperplasia and 02(2.53%) patients had parathyroid carcinoma whereas histopathology was inconclusive in 5 (6.32%) out of the 79 surgically treated patients. Disease recurrence was seen in 13 out of 79(16.45%) patients who underwent surgery. CONCLUSION: Primary hyperparathyroidism is associated with significant morbidity in our population. Targeted measures like improving patient awareness, routine calcium screening, vitamin D supplementation and a high index of suspicion by the clinician may help in early diagnosis of the condition and thus reduce morbidity.

Presentation, Management, and Outcomes of Nonfunctioning Pituitary Adenomas: An Experience from a Developing Country.

Objective The goal of this study was to evaluate the presentation, management, and clinical outcome of nonfunctioning pituitary adenomas (NFPAs) in a tertiary care setup. Methods We conducted a retrospective review of patient records of 157 patients with the diagnosis of NFPA managed at Aga Khan University Hospital, a tertiary care hospital in Karachi, Pakistan from January 1, 2007, to December 31, 2017. We collected data on basic demographic characteristics, signs, and presenting symptoms, management, and outcomes. Data analysis was performed by using Stata, Version 12 (StataCorp LLC, College Station, TX). Results Most patients in the study were men (59%), and the mean age of the study population was 48 ± 14 years. The main presentations of NFPA were visual disturbance (77%) and headache (55%). In 78% of patients, the tumor was >1 cm on MRI. Most (87%) of patients underwent surgical resection, and of those, 93% received transsphenoidal surgery that was well tolerated. In the study population, 31% of patients had transient, 9% had permanent diabetes insipidus, and 25% developed hyponatremia. Of those in the study, 53% had low cortisol, 57% had hypothyroidism, and 27% needed sex hormone replacement after surgery. Residual tumor was confirmed in 43% of patients by postoperative MRI. Tumor recurrence and regrowth occurred in 17 patients and required repeat resection or radiosurgery. Conclusion In Pakistan, patients with NFPAs are more likely to present during the later stage, with larger adenoma and compressive symptoms compared to patients in developed countries. For the detection of residual disease and tumor recurrence, close screening and a multidisciplinary approach are needed after surgery.

Correlation between MR spectroscopy and histology in detection of prostatic carcinoma.

OBJECTIVE: To determine the diagnostic accuracy of magnetic resonance spectroscopy in the detection of prostatic carcinoma. METHODS: This descriptive, cross-sectional study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, from July 24, 2014, to January 23, 2015, and comprised patients who had been screened for prostate cancer. Using non-probability purposive sampling, all magnetic resonance spectroscopy scans were interpreted by three radiologists. Male patients aged 45-70 years, diagnosed with suspicious heterogeneous mass in peripheral zone on ultrasound and who had prostatic specific antigen levels value >4.0 ng/ml were included. Three dimensional magnetic resonance spectroscopy imaging data was acquired. Data was analysed using SPSS 21. Diagnostic accuracy of the procedure was determined by taking histopathology as the gold standard. RESULTS: There were 224 patients with an overall mean age of 55.63±6.34 years (range: 45-70 years). The strong perfect correlation of 0.82 was found by Kappa statistics between magnetic resonance spectroscopy and histopathology results and a good diagnostic accuracy (92.8%) of magnetic resonance spectroscopy testing was observed for the detection of prostate carcinoma. Pooled sensitivity was 92.2% and specificity was 94.6% for the diagnosis of prostate carcinoma. CONCLUSIONS: A strong correlation was found between magnetic resonance spectroscopy and histopathology results to detect prostate carcinoma.