GRADE-ADOLOPMENT of hyperthyroidism treatment guidelines for a Pakistani context

INTRODUCTION

The prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of hyperthyroidism in Pakistan.

METHODS

We employed the GRADE-ADOLOPMENT approach utilizing the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.

RESULTS

The source guideline included a total of 124 recommendations, out of which 71 were adopted and 49 were excluded. 4 recommendations were carried forward for adaptation via the ETD process, with modifications being made to 2 of these. The first addressed the need for liver function tests (LFTs) amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs (ATDs). The second pertained to thyroid status testing post-treatment by radioactive iodine (RAI) therapy for Graves' Disease (GD). Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management.

CONCLUSION

Our newly developed hyperthyroidism CPGs for Pakistan contain two context-specific modifications that prioritize patients' finances during the course of hyperthyroidism management and to limit the overuse of laboratory testing in a resource-constrained setting. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations.

Nanozymes and carbon-dots based nanoplatforms for cancer imaging, diagnosis and therapeutics: Current trends and challenges

Cancer patients face a significant clinical and socio-economic burden due to increased incidence, mortality, and poor survival. Factors like late diagnosis, recurrence, drug resistance, severe side effects, and poor bioavailability limit the scope of current therapies. There is a need for novel, cost-effective, and safe diagnostic methods, therapeutics to overcome recurrence and drug resistance, and drug delivery vehicles with enhanced bioavailability and less off-site toxicity. Advanced nanomaterial-based research is aiding cancer biologists by providing solutions for issues like hypoxia, tumor microenvironment, low stability, poor penetration, target non-specificity, and rapid drug clearance. Currently, nanozymes and carbon-dots are attractive due to their low cost, high catalytic activity, biocompatibility, and lower toxicity. Nanozymes and carbon-dots are increasingly used in imaging, biosensing, diagnosis, and targeted cancer therapy. Integrating these materials with advanced diagnostic tools like CT scans and MRIs can aid in clinical decision-making and enhance the effectiveness of chemotherapy, photothermal, photodynamic, and sonodynamic therapies, with minimal invasion and reduced collateral effects.

Estimation of 10-Year Fracture Risk with and without Bone Mineral Density in Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis affecting 0.5-1.0% of the general population worldwide and although RA is properly considered a disease of the joints, it can cause a variety of extra-articular manifestations. This study was performed to find out any discrepancy in fracture risk estimates with and without bone mineral density (BMD) in rheumatoid arthritis (RA) patients. This observational cross-sectional study was carried out in the Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh from July 2013 to July 2015. Total 65 consecutive patients with RA fulfilling ACR/EULAR criteria aged 40-90 year were recruited. Ten year fracture risk of these patients was evaluated by the FRAX score with and without BMD and differences were observed. FRAX score without BMD revealed that major fracture risk was low in 58(89.2%) patients, moderate in 7(10.8%) patients but re-estimation with BMD revealed that 55(84.6%) patients remained in low risk group, 8(12.3%) patients in moderate risk group and 2(3.1%) patients went to the high risk group. In case of hip fracture risk without BMD, risk was low in 58(89.2%) patients, high in 7(10.8%) patients; but with BMD, 50(76.9%) patients remained in low risk group but risk of 15(23.1%) patients became high. Almost all the high risk patients (93.3%) were ≥55 years of age. Increasing age, female sex, disease duration and use of steroid were positively correlated with increased FRAX score where as high BMI and high BMD were associated with low FRAX score. But in multivariate analysis it was found that only relation with age was at statistically significant level. Significant numbers of patients with rheumatoid arthritis have high risk of fracture especially hip fracture. The mean of FRAX score increased in both major & hip osteoporotic fracture risk after adding BMD. More than half of the patients above fifty five years or more had high risk of fracture. So, BMD should be done in patients aged more than fifty five.

Deciphering the emerging role of phytocompounds: Implications in the management of drug-resistant tuberculosis and ATDs-induced hepatic damage

Tuberculosis is a disease of poverty, discrimination, and socioeconomic burden. Epidemiological studies suggest that the mortality and incidence of tuberculosis are unacceptably higher worldwide. Genomic mutations in embCAB, embR, katG, inhA, ahpC, rpoB, pncA, rrs, rpsL, gyrA, gyrB, and ethR contribute to drug resistance reducing the susceptibility of Mycobacterium tuberculosis to many antibiotics. Additionally, treating tuberculosis with antibiotics also poses a serious risk of hepatotoxicity in the patient's body. Emerging data on drug-induced liver injury showed that anti-tuberculosis drugs remarkably altered levels of hepatotoxicity biomarkers. The review is an attempt to explore the anti-mycobacterial potential of selected, commonly available, and well-known phytocompounds and extracts of medicinal plants against strains of Mycobacterium tuberculosis. Many studies have demonstrated that phytocompounds such as flavonoids, alkaloids, terpenoids, and phenolic compounds have antibacterial action against Mycobacterium species, inhibiting the bacteria's growth and replication, and sometimes, causing cell death. Phytocompounds act by disrupting bacterial cell walls and membranes, reducing enzyme activity, and interfering with essential metabolic processes. The combination of these processes reduces the overall survivability of the bacteria. Moreover, several phytochemicals have synergistic effects with antibiotics routinely used to treat TB, improving their efficacy and decreasing the risk of resistance development. Interestingly, phytocompounds have been presented to reduce isoniazid- and ethambutol-induced hepatotoxicity by reversing serum levels of AST, ALP, ALT, bilirubin, MDA, urea, creatinine, and albumin to their normal range, leading to attenuation of inflammation and hepatic necrosis. As a result, phytochemicals represent a promising field of research for the development of new TB medicines.

Reviewing the Prospective Pharmacological Potential of Isothiocyanates in Fight against Female-Specific Cancers

Gynecological cancers are the most commonly diagnosed malignancies in females worldwide. Despite the advancement of diagnostic tools as well as the availability of various therapeutic interventions, the incidence and mortality of female-specific cancers is still a life-threatening issue, prevailing as one of the major health problems worldwide. Lately, alternative medicines have garnered immense attention as a therapeutic intervention against various types of cancers, seemingly because of their safety profiles and enhanced effectiveness. Isothiocyanates (ITCs), specifically sulforaphane, benzyl isothiocyanate, and phenethyl isothiocyanate, have shown an intriguing potential to actively contribute to cancer cell growth inhibition, apoptosis induction, epigenetic alterations, and modulation of autophagy and cancer stem cells in female-specific cancers. Additionally, it has been shown that ITCs plausibly enhance the chemo-sensitization of many chemotherapeutic drugs. To this end, evidence has shown enhanced efficacy in combinatorial regimens with conventional chemotherapeutic drugs and/or other phytochemicals. Reckoning with these, herein, we discuss the advances in the knowledge regarding the aspects highlighting the molecular intricacies of ITCs in female-specific cancers. In addition, we have also argued regarding the potential of ITCs either as solitary treatment or in a combinatorial therapeutic regimen for the prevention and/or treatment of female-specific cancers. Hopefully, this review will open new horizons for consideration of ITCs in therapeutic interventions that would undoubtedly improve the prognosis of the female-specific cancer clientele. Considering all these, it is reasonable to state that a better understanding of these molecular intricacies will plausibly provide a facile opportunity for treating these female-specific cancers.

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.

Prospective Epigenetic Actions of Organo-Sulfur Compounds against Cancer: Perspectives and Molecular Mechanisms

Major epigenetic alterations, such as chromatin modifications, DNA methylation, and miRNA regulation, have gained greater attention and play significant roles in oncogenesis, representing a new paradigm in our understanding of cancer susceptibility. These epigenetic changes, particularly aberrant promoter hypermethylation, abnormal histone acetylation, and miRNA dysregulation, represent a set of epigenetic patterns that contribute to inappropriate gene silencing at every stage of cancer progression. Notably, the cancer epigenome possesses various HDACs and DNMTs, which participate in the histone modifications and DNA methylation. As a result, there is an unmet need for developing the epigenetic inhibitors against HDACs and DNMTs for cancer therapy. To date, several epigenetically active synthetic inhibitors of DNA methyltransferases and histone deacetylases have been developed. However, a growing body of research reports that most of these synthetic inhibitors have significant side effects and a narrow window of specificity for cancer cells. Targeting tumor epigenetics with phytocompounds that have the capacity to modulate abnormal DNA methylation, histone acetylation, and miRNAs expression is one of the evolving strategies for cancer prevention. Encouragingly, there are many bioactive phytochemicals, including organo-sulfur compounds that have been shown to alter the expression of key tumor suppressor genes, oncogenes, and oncogenic miRNAs through modulation of DNA methylation and histones in cancer. In addition to vitamins and microelements, dietary phytochemicals such as sulforaphane, PEITC, BITC, DADS, and allicin are among a growing list of naturally occurring anticancer agents that have been studied as an alternative strategy for cancer treatment and prevention. Moreover, these bioactive organo-sulfur compounds, either alone or in combination with other standard cancer drugs or phytochemicals, showed promising results against many cancers. Here, we particularly summarize and focus on the impact of specific organo-sulfur compounds on DNA methylation and histone modifications through targeting the expression of different DNMTs and HDACs that are of particular interest in cancer therapy and prevention.

An Attention towards the Prophylactic and Therapeutic Options of Phytochemicals for SARS-CoV-2: A Molecular Insight

The novel pathogenic virus was discovered in Wuhan, China (December 2019), and quickly spread throughout the world. Further analysis revealed that the pathogenic strain of virus was corona but it was distinct from other coronavirus strains, and thus it was renamed 2019-nCoV or SARS-CoV-2. This coronavirus shares many characteristics with other coronaviruses, including SARS-CoV and MERS-CoV. The clinical manifestations raised in the form of a cytokine storm trigger a complicated spectrum of pathophysiological changes that include cardiovascular, kidney, and liver problems. The lack of an effective treatment strategy has imposed a health and socio-economic burden. Even though the mortality rate of patients with this disease is lower, since it is judged to be the most contagious, it is considered more lethal. Globally, the researchers are continuously engaged to develop and identify possible preventive and therapeutic regimens for the management of disease. Notably, to combat SARS-CoV-2, various vaccine types have been developed and are currently being tested in clinical trials; these have also been used as a health emergency during a pandemic. Despite this, many old antiviral and other drugs (such as chloroquine/hydroxychloroquine, corticosteroids, and so on) are still used in various countries as emergency medicine. Plant-based products have been reported to be safe as alternative options for several infectious and non-infectious diseases, as many of them showed chemopreventive and chemotherapeutic effects in the case of tuberculosis, cancer, malaria, diabetes, cardiac problems, and others. Therefore, plant-derived products may play crucial roles in improving health for a variety of ailments by providing a variety of effective cures. Due to current therapeutic repurposing efforts against this newly discovered virus, we attempted to outline many plant-based compounds in this review to aid in the fight against SARS-CoV-2.

Adolopment of adult diabetes mellitus management guidelines for a Pakistani context: Methodology and challenges

Introduction

Pakistan has the highest national prevalence of type 2 diabetes mellitus (T2DM) in the world. Most high-quality T2DM clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local T2DM CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of adult DM in Pakistan.

Methods

We employed the GRADE-ADOLOPMENT approach utilizing the T2DM CPG of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes - 2021 as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.

Results

The source document contained 243 recommendations, 219 of which were adopted without change, 5 with minor changes, and 18 of which were excluded in the newly created Pakistani guidelines. One recommendation was adapted: the recommended age to begin screening all individuals for T2DM/pre-diabetes was lowered from 45 to 30 years, due to the higher prevalence of T2DM in younger Pakistanis. Exclusion of recommendations were primarily due to differences in the healthcare systems of Pakistan and the US, or the unavailability of certain drugs in Pakistan.

Conclusion

A CPG for the management of T2DM in Pakistan was created. Our newly developed guideline recommends earlier screening for T2DM in Pakistan, primarily due to the higher prevalence of T2DM amongst younger individuals in Pakistan. Moreover, the systematic methodology used is a significant improvement on pre-existing T2DM CPGs in Pakistan. Once these evidence based CGPs are officially published, their nationwide uptake should be top priority. Our findings also highlight the need for rigorous expanded research exploring the effectiveness of earlier screening for T2DM in Pakistan.

Clinical Presentations of Acquired Hypothyroidism in Children: Experience in a Tertiary Care Hospital in Bangladesh

A cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with acquired hypothyroidism during the period of January 2012 to December 2016. The study was done to find out the clinical presentations and associated disorders of all patients diagnosed with acquired hypothyroidism during the study period. Data were obtained by reviewing the medical records of the patients. Total 277 children were diagnosed of having thyroid disorders. Among them 145(52.3%) had acquired hypothyroidism. The commonest clinical presentations of children with acquired hypothyroidism were short stature (35.0%), excessive weight gain (31.5%), goiter (23.1%) and poor school performance (14.0%). Autoimmune hypothyroidism was found in 34.4% of children, sub-clinical hypothyroidism in 27.5% children and positive family history was found in 15.2% children with acquired hypothyroidism. The common associated diseases were diabetes and impaired glucose tolerance (4.9%), Down syndrome (3.5%), congenital heart disease (2.1%) and primary adrenal insufficiency (1.4%).

Estimation of Serum Lipid Profile among Patients Admitted with Myocardial Infarction in a Tertiary Level Hospital of Bangladesh

Different studies worldwide showed that dyslipidaemia is involved in the pathogenesis of ischemic heart diseases (IHD). This cross sectional descriptive type of observational study was carried out at Mymensingh Medical College Hospital during the period of six months from January 2021 to September 2021 to estimate the lipid profile among patients admitted in the coronary care unit (CCU) with myocardial infarction (MI). Data were collected from purposively selected 343 patients with MI by face to face interview and laboratory investigations using a case record form. Informed written consent of participants was taken prior to interview. Data were analyzed by using SPSS version 21.0. The study results revealed that mean age of the patients with myocardial infarction was 53.16 years with a standard deviation of 11.68 years. Majority of them (284, 82.8%) were male and the remaining (59, 17.2%) were female. Proportion of risk factors for ischaemic heart disease (IHD) were estimated and found that 244(71.1%) patients were smoker; 150(43.7%) had hypertension and 110(32.2%) had family history of IHD. Ninety nine (28.9%) patents were obese with BMI ≥25kg/m². Eighty three (24.2%) patients had diabetes mellitus; 66(19.2%) lead sedentary life and 61(17.8%) patients with myocardial infarction had dyslipidaemia. Mean LDL of patients with myocardial infarction was 103.65±39.73mg/dl; mean total cholesterol (TC) was 189.44±45.41mg/dl; mean TG was 243.11±205.19mg/dl and mean HDL was 39.29±8.98mg/dl. LDL was increased in 10(2.9%) patients; total cholesterol was raised in 121 (35.3%) patients and TG was raised in 195(56.9%) patients. HDL was raised in 26(7.6%) patients and it was lowered in 57(16.6%) patients. Mean LDL, TC, TG and HDL of younger (≤45 years) and older (>45 years) patients were compared and t-test showed no significant difference (p>0.05). Similarly mean LDL, TC, TG and HDL of male and female were compared and again t-test showed no significant difference (p>0.05). Though the pattern of lipid profile was found similar in younger and older patients and in males and females, a significant number of patients (61, 17.8%) with MI had dyslipidaemia which should be address by dietary and lifestyle modification.

Clinical Presentation of Congenital Adrenal Hyperplasia in Children: Experience in a Tertiary Care Hospital of Bangladesh

This cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with congenital adrenal hyperplasia (CAH) from January 2005 to December 2018. The study was aimed to find out the clinical and laboratory profile of all patients at presentation diagnosed with CAH during the study period. Data were obtained by reviewing the medical records of the patients. Total 102 children with CAH were diagnosed during the study period. Among them 68 were female and 34 were male (female to male ratio of 2:1). Median age was 3.5 month (range 0.2-158 month) and 5.5 month (range 1-108 month) in female and male respectively (p=0.42). Family history was available in 93 patients. Consanguinity was present in 16(17.2%), history of sib death in 12(12.9%), other family members were affected in 8(8.6%). Sixty patient (58.8%) had salt-wasting (SW), 39(38.2%) had simple virilizing (SV) and 3(2.9%) had non- classic form of CAH. Median age of presentation was 2 month (range 0.2-70 month) and 42 month (range 0.8-158 month) in SW and SV group respectively (p=0.001) and 119 month (range 108-152 month) in non- classic group. Common presentations were: genital ambiguity (64.7%), vomiting (46.5%), failure to thrive (41.6%), features of early puberty (precocious pseudopuberty) (24.5%), diarrhea (12.0%). Hyperpigmentation was noted in 49.0% of patients. Among the salt-wasting type in male failure to thrive (FTT) was the most common presentation (83.3%), followed by vomiting (75.0%). In female genital ambiguity was the commonest presentation (97.2%), followed by vomiting (77.1%). Among the simple virilizing type in male early puberty was the commonest presentation (100%) and genital ambiguity was the presenting feature in all the female (100.0%).

Corona Virus Disease 2019 (COVID-19) Diagnostic Tests: A Glimpse

Mass testing for COVID-19 infection is one of the core measures in tackling the global spread of the disease. Testing is vital to diagnose and estimate cases, attack rates and case fatality rates- critical data for policy-making. As COVID-19 continues to spread globally, the demand for more extensive laboratory testing and innovative technology increases. However, countries around the world have been struggling to keep up pace with the worldwide demand to expand testing strategy. The pandemic evolves, so does our knowledge and understanding of diagnostic tests of COVID-19. Here we aim to review major challenges related to COVID-19 diagnostic tests and future development. So, the ongoing urgency and demand for tests would certainly steer the rapid uptake of novel techniques, which in turn would boost our understanding of diagnostic tests for COVID-19.

AB0546 DETERMINANTS OF VASCULITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Among the manifestations of SLE, vasculitic presentation is common. This study was aimed to identify the predictors of vasculitis in SLE patients.

Objectives

To identify the determinants of vasculitis in SLE patients.

Methods

The study was conducted in the Department of Rheumatology, BSMMU, Dhaka from December 2019 to January 2021. A total 168 consecutive confirmed cases of SLE patients were enrolled. The patients were evaluated for the features of vasculitic rashes, digital gangrene, mesenteric vasculitis, mononeuritis multiplex. The cutaneous vasculitis was confirmed by a dermatologist. Study subjects were grouped into vasculitic and no vasculitic groups. The disease activity and damage were assessed using SLEDAI and SLICC/ACR DI. The rate of vasculitis was expressed in percentage. The multivariate logistic regression analysis was done to determine the independent predictors of vasculitis in SLE. P value <0.05 was considered significant.

Results

Rate of lupus vasculitis was 14.3%. The features shown significant difference between vasculitic and no vasculitic groups were: ACLE (79.2% vs. 18.8%, p<0.001), oral ulcer (70.8% vs. 13.2%, p<0.001), alopecia (83.3% vs. 27.1%, p<0.001), Raynaud’s phenomenon (20.8% vs. 5.6%, p=0.011), fever (54.2% vs. 25.0%, p=0.002), arthritis (70.8% vs. 29.9%, p<0.001), pregnancy loss (68.8% vs. 32.7%, p=0.003), lupus nephritis (25.0% vs. 45.1%, p=0.032), seizure (8.3% vs. 0.7%, p=0.027), pleurisy (8.3% vs. 0.7%, p=0.027), leucopenia (8.3% vs. 1.4%, p=0.049), anti ds-DNA positivity (87.5% vs. 62.5%, p=0.008), hypocomplementemia (87.5% vs. 59%, p=0.003), higher mean SLEDAI (p<0.001) and SLICC/ACR damage index score (p<0.001). Though not significant the rate of antiphospholipid antibody positivity was high (69.2% vs. 42.9%, p=0.052) in vasculitis group. In multivariate logistic regression analysis, higher SLEDAI score (OR = 1.296, 95% CI =1.114-1.508) was positively and lupus nephritis (OR= 0.055, 95% CI =0.007-0.413) was negatively associated with lupus vasculitis.

Conclusion

In SLE, vasculitic presentation is common. Higher the SLEDAI score greater the chance of lupus vasculitis.

References

[1]Aringer, M., Costenbader, K., Daikh, D., Brinks, R., Mosca, M., Ramsey-Goldman, R., et al., (2019). 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis & Rheumatology, 71(9), pp.1400-1412.

[2]Drenkard, C., Villa, A., Reyes, E., Abello, M. and Alarcón-Segovia, D. (1997). Vasculitis in systemic lupus erythematosus. Lupus, 6(3), pp.235-242.

[3]Ramos-Casals, M., Nardi, N., Lagrutta, M., Brito-Zerón, P., Bové, A., Delgado, et al., (2006). Vasculitis in Systemic Lupus Erythematosus. Medicine, 85(2), pp.95-104.

Table 1.

Comparison of clinical features of Lupus vasculitis and without vasculitis (n=168)

Clinical featuresLupus vasculitis (n=24) n (%)Without vasculitis (n=144) n (%)p-valueFever13 (54.2)36 (25.0)0.002γSLE specific skin lesionsACLE19 (79.2)27(18.8)<0.001γSCLE1 (4.2)6(4.2)0.500*SLE non-specific skin lesionsOral ulcer17 (70.8)19 (13.2)<0.001γAlopecia20 (83.3)39 (27.1)<0.001γ   Raynaud’s5 (20.8)8 (5.6)0.011*Arthritis17 (70.8)43 29.9)<0.001γLupus nephritisa6 (25.0)65 (45.1)0.032γNeuro psychiatricSeizure2 (8.3)1 (0.7)0.027*Psychosis1 (4.2)2 (1.4)0.186*SerositisPleurisyPericarditis2 (8.3)1 (4.2)1 (0.7)3 (2.1)0.027*0.231*Pregnancy loss11/16 (68.8)32/98 (32.7)0.003γDVT1 (4.2)6 (4.2)0.500*APS3 (12.5)11 (7.6)0.213*AVN1 (4.2)2 (1.4)0.186*Pulmonary HTN2 (8.3)3 (2.1)0.074*

* Fisherʼs eхact test; γ chi-Square test, p < 0.05 is considered statistically significant, n: Number, %: Percent.

ACLE: Acute Cutaneous Lupus Erythematosus, SCLE: Sub-acute Cutaneous Lupus Erythematosus, DVT: Deep Vein Thrombosis, APS: Anti Phospholipid Antibody Syndrome, AVN: Avascular necrosis, HTN: Hypertension,

a: all diagnosed cases of lupus nephritis, presented with or without flare

Acknowledgements

We acknowledge all of our patients for their kind participation in this study. We also acknowledge Prof. Syed Atiqul Haq, Prof. Minhaj Rahim Choudhury, Prof. Abu Shahin, Dr. Md. Masudul Hasaan, Dr. Shamim Ahmed, Dr. Abul Kalam Azad, Department of rheumatology, BSMMU for their support and kind help during the work. At the end we acknowledge BSMMU authority for their support in conducting the study.

Disclosure of Interests

None declared

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). ---Continue

Levothyroxine dosages during pregnancy among hypothyroid women. An experience from a tertiary care center of Karachi, Pakistan, based on data from Maternal Hypothyroidism on Pregnancy Outcomes Study (MHPO-5)

Objectives

The dosage of levothyroxine (LT4) during pregnancy differs among different ethnic groups worldwide. These differences are due to variations in geographical iodine distribution, autoimmunity, and variations in thyrotropin (TSH) targets for pregnancy. To the best of our knowledge, we report the levothyroxine dosage prescribed during pregnancy in hypothyroid women, for the first time from Pakistan.

Results

Levothyroxine dosage of 280 hypothyroid women during pregnancy were reviewed. The median LT4 dosages prescribed before conception was 85.7 mcg per day which increased by 14.3 mcg per day in the first trimester (P 0.001). A significant difference in dosage was observed between controlled and uncontrolled TSH groups in the first trimester (P 0.05). Lower LT4 dosage was prescribed for subclinical hypothyroid women as compared to overt hypothyroid cases, whereas dosages did not differ according to autoimmune status in the latter part of gestation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13104-022-05984-7.

Clinicopathological Characteristics and Treatment Outcome of Patients with Metastatic Differentiated Thyroid Cancer

BACKGROUND AND OBJECTIVE

Differentiated thyroid carcinoma (DTC) is a slow-growing tumour with 20% of the cases having distant metastasis. Its prognosis can vary by its histological characteristics, extension and spread. The data on metastatic DTC patients in Pakistan is scarce; therefore, the purpose of our study was to assess the clinicopathological characteristics and treatment outcomes of metastatic DTC in our population.

METHODS

This retrospective, single-centre study was carried out on 117 patients with metastatic DTC with their age at diagnosis, gender, tumour size and extent and spread of the tumour, and its histologic characteristic recorded. The treatment they received and the outcome in terms of status, at last, follow-up were also recorded.

RESULTS

The mean age of diagnosis was found to be 46.6 ± 17.2 years with an almost equal male to female ratio. The most common site of metastasis was the lung followed by bone. Papillary carcinoma was the most common subtype with 89.7% of the cases followed by follicular carcinoma occurring in 7.7%. The overall survival in years was found to be 5.6 ± 2.6 years. Ninety-six per cent had complete surgical resection followed by radioactive iodine (RAI) in 91.5%.

CONCLUSION

Our study shows that the most significant factors in predicting the outcome in metastatic DTC are age, an extrathyroidal extension of the primary tumour and distant metastasis. However, further multicentric studies done on a much larger population will be needed to further support and strengthen our results.

Phytocompounds from the medicinal and dietary plants: Multi-target agents for cancer prevention and therapy

Cervical cancer is the fourth leading cause of cancer death among women worldwide. Due to cervical cancer's high incidence and mortality, there is an unmet demand for effective diagnostic, therapeutic, and preventive agents. At present, the preferred treatment strategies for advanced metastatic cervical cancer include surgery, radiotherapy, and chemotherapy. However, cervical cancer is gradually developing resistance to chemotherapy, thereby reducing its efficacy. Over the last several decades, phytochemicals, a general term for compounds produced from plants, have gained attention for their role in preventing cervical cancer. This role in cervical cancer prevention has garnered attention on the medicinal properties of fruits and vegetables. Phytochemicals are currently being evaluated for their ability to block proteins involved in carcinogenesis and chemoresistance against cervical cancer. Chemoresistance to cancer drugs like cisplatin, doxorubicin, and 5-fluorouracil has become a significant limitation of drug-based chemotherapy. However, the combination of cisplatin with other phytochemicals has been identified as a promising alternative to subjugate cisplatin resistance. Phytochemicals are promising chemo-preventive and chemotherapeutic agents as they possess antioxidant, anti-inflammatory, and anti-proliferative potential against many cancers, including cervical cancer. Furthermore, the ability of the phytochemicals to modulate cellular signaling pathways through up and down regulation of various proteins has been claimed for their therapeutic potential. Phytochemicals also display a wide range of biological functions, including cell cycle arrest, apoptosis induction, inhibition of invasion, and migration in cervical cancer cells. Numerous studies have revealed the critical role of different signaling proteins and their signaling pathways in the pathogenesis of cervical cancer. Here, we review the ability of several dietary phytochemicals to alter carcinogenesis by modulating various molecular targets.

TB prevalence among patients with diabetes in Bangladesh

OBJECTIVE: 1) To assess the prevalence of TB among patients with diabetes mellitus (DM) attending diabetic care centres in Bangladesh, and 2) to compare TB- and DM-related sociodemographic and other factors in diabetic patients who had TB and those who did not.METHODS: This cross-sectional study was conducted from 1 June 2019 to 31 March 2020 in 108 centres of the Diabetic Association of Bangladesh (BADAS), with a sample size of 3,649 patients with DM. Data were collected by face-to-face interview using semi-structured questionnaire from each patient/guardian. Other ethical issues were also maintained.RESULTS: Out of 3,649 patients with DM, 676 presumptive TB cases were identified and tested; from them, 85 patients were detected as TB cases. Another 39 patients were already diagnosed and on anti-TB medication. Prevalence of TB among patients with DM attending diabetic care centres was 3.4%. Prevalence was higher in female than male (4.0% vs 2.6%). Underweight (9.0%) patients and patients having diabetes for more than 10 years (7.1%) had a higher prevalence of TB.CONCLUSION: TB prevalence was over 3% among study population with DM. Periodic screening and active case finding among DM patients should be strengthened to reduce the risk of TB infection among DM patients.

Evaluation of Diagnostic Utility of the Immunohistochemical Markers in the Accurate Diagnosis of Thyroid Neoplasms: A Retrospective Study in a Tertiary Care Hospital of Pakistan

Background

Thyroid cancer is the most common endocrine malignancy across the globe and is among the fastest-growing cancers worldwide. Thyroid tumors are divided into differentiated and non-differentiated, with each having further subtypes, with papillary carcinoma being the most common one. Immunohistochemical (IHC) markers’ studies play a crucial role in the accurate diagnosis of thyroid neoplasms. To the best of our knowledge, this topic has been the least researched in Pakistan.

Objectives

This study was designed to determine the diagnostic utility of immunohistochemical markers in the diagnosis of thyroid cancers in correlation with histopathology as the gold standard.

Methods

This retrospective, single-center study was carried out on 124 patients with thyroid cancer treated at our institution. The type of cancer, patient gender, and immunohistochemical markers used in each patient were recorded, and the sensitivity and specificity of the markers used in each tumor case were calculated.

Results

The mean age of patients was found to be 48.5 ± 15.6 years; 56 (45.2%) of the patients were male and 68 (54.8%) were female. Out of the 124 patients, 75 (60.5%) had papillary, 19 (15.3%) had medullary, 16 (12.9%) had anaplastic, and eight (6.5%) had follicular carcinoma, while six (4.8%) had primary thyroid lymphoma. Thyroglobulin was found to be a reliable tumor marker in both papillary and follicular tumors. The cluster of differentiation56 (CD56) negativity was a useful double panel study along with thyroglobulin in the confirmation of papillary carcinomas. Tumor markers used in medullary carcinoma include calcitonin, chromogranin, and synaptophysin. Cytokeratin AE 1 and vimentin were found to be useful for anaplastic tumors, while Ki 67 was a reliable marker for primary thyroid lymphoma.

Change of Hemoglobin Level among Exclusively Breastfed Term and Preterm Babies up to Six Months of Age

There is progressive increase of Hb levels is observed during course of intrauterine development of fetus but high concentrations found at birth. In preterm neonate normal Hb is characteristically deviated from term neonate. Breast milk is the only natural ideal food for both term and preterm babies from birth up to 6 months. Preterm milk was found to contain significantly higher concentrations nutrients particularly iron than term milk. Preterm human milk is more suitable for the premature infant than term human milk. As Hb concentration varies in term and preterm babies in different counties in different feeding practices. The purpose of this longitudinal descriptive study is to find out the pattern of changes in the Hb level among exclusively breastfed preterm and term infants during the first six months of life. This study was carried in the Neonatal Intensive Care Unit (NICU), Mymensingh Medical College Hospital (MMCH), Mymensingh from September 2016 to February 2018. One hundred fifty (150) neonates both term and preterm were included in this study and followed up to 6 months of age. After admission informed written consent was taken from parents, thorough history taking and clinical examination were done. Data were collected in a pre-designed case record form. All the babies of Group A provided 2mg/kg iron supplementation from 6 weeks for 2 months for universal recommendation. Hb level was measured of all exclusively breast feed babies at admission after birth then next follow-up at 6 weeks, 3 months and 6 months. All information regarding history, anthropometrics measurement, Hb level was recorded in structural questionnaire. Data analysis was done by SPSS version 20.0. Male were predominant in both groups. Most of the preterm (72.0%) and term babies (65.3%) were delivered by vaginal route. Mean Hb level was found significantly higher among preterm babies than term babies after birth were 16.55g/dl and 15.98g/dl respectively. Sharp fall of Hb concentration was observed after birth up to 6 weeks in both preterm and term babies but Hb level was found significantly lower in preterm in comparison to term babies (9.27gm/dl vs. 9.58gm/dl). In term babies, even after 6 weeks fall of Hb level continued to 3 months of age followed by gradual increase up to 6 months without iron supplementation. Hb level of in preterm babies gradually increased from 6 weeks up to 6 months with universal iron supplementation. Hb level fall sharply up to 6 weeks in both exclusively breastfed term and preterm babies but even after 6 weeks term babies experienced gradual fall of Hb levels up to 3 months. Hb level increases in exclusively breast-fed term babies without iron supplementation from 3 months of age. Hb level in exclusively breastfed preterm babies increase from 6 weeks onward might be effect of universal iron supplementation.

Prevalence of Comorbidities among Patients with Acromegaly

Background and Objective

Acromegaly is a chronic disorder resulting from excessive secretion of growth hormone and (GH) and insulin-like growth factor 1 (IGF-1) and is associated with several comorbidities. These complications contribute significantly to morbidity and mortality associated with this condition thus early diagnosis leads to better outcomes. There have been studies in other countries to assess the comorbidities associated with acromegaly. However, we do not have any recent data with regards to Pakistan. So, in order to demonstrate the prevalence of demographics, hormonal disorders, and other complications associated with acromegaly we conducted this study.

Methods

It is a retrospective review of patients' records presented to the tertiary care Hospital, Karachi, Pakistan for the diagnosis and management of acromegaly and the complications associated with this condition between the time periods 2000 till 2020. A total of 89 patients fulfilled the inclusion criteria of acromegaly and were included in the study. Comorbid conditions were described based on current guidelines. Patient baseline characteristics were recorded along with other complications arising during treatment.

Results

Eighty-nine patients were included. 64% were male, over 70% were older than 30 years old and more than 40% of patients had BMI greater than 30. HTN, pre-hypertension, and CCF were reported in 35.95%, 3.37%, and 6.74%. Diabetes mellitus, hypocortisolism, hypothyroidism, hypogonadism, and hyperprolactinemia were reported in 39.32%, 38.20%, 37.07%, 34.46%, and 16.85% of cases. The prevalence of osteoarthritis, blood disorder, skin changes, thyroid cancer, and spinal stenosis was found out to be around 1.12% each.

Conclusions

Acromegaly is associated with cardiovascular and endocrinal disorders. Screening for these disorders at the time of diagnosis can lead to early management and better outcomes translating into decreased mortality.