Glucose monitoring in pregnancy complicated by diabetes.

Diabetes in pregnancy is associated with adverse maternal and neonatal outcomes. Due to variations in insulin resistance throughout pregnancy there is a continuous need to implement Medical Nutrition Therapy (MNT), exercise and pharmacological treatments which have to be escalated. Self-monitoring of blood glucose (SMBG) is integral to the management of diabetes in pregnancy. Proper implementation of SMBG in pregnant women with diabetes requires patient education and understanding of its applications and limitations. Real-time results enable individuals to make informed daily self-care decisions regarding diet, exercise, and insulin. Retrospective analysis of SMBG data enables clinicians to develop individualized care plans, informing decisions related to insulin initiation and adjustment and the possible needs for interventions or hospitalization to improve inadequate self-monitoring

Minimally symptomatic severe hypercalcaemia in a patient with parathyroid carcinoma.

The case of a 38 years old man with generalized pains fatigue, anorexia, constipation, polyuria serum calcium level of 20.6mg/dl in paired renal function parathyroid hormone is presented. Sestamibi scan showed a functioning left inferior parathyroid tumor, which was successfully removed. Before surgery he was managed with rehydration, diuretics and pamidronate infusion. Five months post surgery the serum calcium levels are normal and renal function has improved

Resistant thyrotoxicosis in a patient with graves disease: a case report

Background: Conventional management of thyrotoxicosis includes antithyroid drugs, radioactive iodine, and surgery while adjunctive treatment includes beta-blockers, corticosteroids, inorganic iodide and iopanoic acid. Very rarely, patients may be resistant to these modalities and require additional management. Case Presentation: A 50-year-old lady presented with weight loss and palpitations diagnosed as atrial fibrillation. Her past history was significant for right thyroid lobectomy for thyrotoxicosis. Thyroid functions tests at this presentation showed free T4 of 6.63 ng/dl (normal range: 0.93-1.7) and TSH of \u3c0.005 μIU/mL (normal range: 0.4-4.0). She was given aspirin, propranolol, heparin and carbimazole; however free T4 failed to normalize. Switching to propylthiouracil (PTU) did not prove successful. She was then given high doses of prednisolone (1 mg/kg/day) and lithium (400 mg twice daily) which prepared the patient for radioactive iodine treatment by reducing free T4 levels (2.82 ng/dl). Two doses of radioactive iodine were then administered 6 months apart. Subsequently she became hypothyroid and was started on thyroid replacement therapy. Conclusion: This case highlights management options in patients with resistant thyrotoxicosis. Radioactive iodine and surgery are definitive modes of treatment in such complex cases while steroids and lithium play an important role in preparing patients for more definitive treatment

Impact of Ramadan fasting on thyroid status and quality of life in patients with primary hypothyroidism: A prospective cohort study from Karachi, Pakistan

Objective: Ramadan is the ninth month in the lunar calendar, during which Muslims fast from predawn to sunset and major changes occur in their dietary, sleep, and physical activity patterns. Most patients with hypothyroidism are unable to comply with the proper timings of levothyroxine (LT4) administration. The objective of the study was to determine the change in thyroid-stimulating hormone (TSH) level and quality of life (QOL) before and after Ramadan in patients with primary hypothyroidism.Methods: This prospective cohort study included adult patients on stable doses of LT4 who fasted for at least 20 days during the month of Ramadan in the Islamic year 1437 Hijri (June/July 2016). Baseline characteristics and TSH levels were recorded on all consenting patients within 6 weeks prior to Ramadan. Post-Ramadan TSH was tested within 1 to 2 weeks after Eid-ul-Fitr.Results: During the study period, 64 patients with hypothyroidism were enrolled, of which 58 were female. The mean age of participants was 44.2 ± 13.2 years. Average daily dose of LT4 was 95.3 ± 35.4 μg. On average, patients fasted for 26.5 days and missed a dose of LT4 on 1.27 days. Mean TSH pre-Ramadan was 2.37 ± 1.35 mIU/L, and post-Ramadan, it was 4.69 ± 3.87 mIU/L. Mean difference between TSH pre- and post-Ramadan was 2.32 ± 3.80 mIU/L ( P\u3c.001). However, the difference in TSH was not significantly different between those who were compliant with meals and LT4 interval versus those who were not (compliant, 2.04 mIU/L; noncompliant, 3.15 mIU/L; P = .30). Overall, an increase in QOL scores in the domains of physical health, psychological health, and social relationships was observed after Ramadan.Conclusion: We observed statistically significant changes in TSH concentrations after the month of Ramadan in hypothyroid patients who fasted. The change in TSH was not affected by timing of LT4 intake and interval from meal

Biomarkers for impending risk of osteoporosis in premenopausal women

Objective: To compare \u27cytokines\u27 and \u27bone turnover markers\u27 in pre- and post-menopausal women and identify their relationship with bone mineral density (BMD) in both groups. Study Design: A cross-sectional study.Place and duration of study: Department of Biological & Biomedical Sciences, The Aga Khan University, Karachi, Pakistan, from June 2017 to August 2019.Methodology: Groups comprised of healthy premenopausal and postmenopausal women from the general population belonging to different ethnic groups and socio-economic status. Serum cytokines and bone turnover markers were assessed by solid-phase immunoassays, BMD (gm /cm2)] measurement was performed by dual-energy X-ray absorptiometry at the hip, lumbar spine, and proximal femur. Results were interpreted as a sum of T scores calculated by BMD of the above-mentioned sites.Results: Cytokines and bone turnover markers were significantly high in post-menopausal women (p\u3c0.001). A negative correlation (r = 0.32) of TNF α with BMD (total T scores) observed in premenopausal women was found to be significant, however, no significant association of BMD was detected in post-menopausal women.Conclusion: There is an increase in the production of cytokines and bone turnover markers after menopause. TNF-α follows this usual pattern of increase in post-menopausal women and can predict impending bone loss and osteopenia in premenopausal females. Therefore, estimation of this cytokine in pre-menopausal women can give a fair indication of a decline in BMD, bone health, and risk of future osteoporosis. Key Words: Bone mineral density, Cytokines, Bone turnover markers, Osteoporosis

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 \u3c 0.01), BMI (31.4±5.8, 31.8±5.8 from 32.4±5.9kg/m2, p \u3c 0.01) and in creatinine (0.71±0.1, 0.75±0.1 from 0.79±0.1 mg/dl, p \u3c 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\u27s 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

Neonatal outcomes and congenital anomalies in pregnancies affected by hypothyroidism

Background: Maternal hypothyroidism has been reported to have concerns over neonatal outcomes, not only in the context of neurocognitive development but also in the short term as birth weight and neonatal jaundice.Patients and methods: We conducted a cross-sectional retrospective study on 638 cases who delivered live births in the Aga Khan University Hospital after ethical approval. Data were collected on hypothyroid pregnant females who were diagnosed before conception or during their antenatal visits during the year 2008-2016. Neonatal outcomes were noted for birth weight, maturity, and neonatal jaundice, neonatal hypothyroidism, neonatal respiratory distress syndrome, sepsis, hypocalcaemia, congenital anomalies, need for intensive care admission, and neonatal death. Subgroup analysis was performed on the timing of diagnosis of maternal hypothyroidism. Data analysis was performed on Statistical Package for the Social Sciences version 20.0.Results: Neonatal jaundice was the most common neonatal outcome (37.6%) in our cohort of 662 live births. Nearly 15% required intensive care unit admission, however, neonatal death was very rare. The most common clinically significant congenital anomalies were cardiovascular defects, whereas Mongolian spots were the commonest congenital condition to report. There is a statistically significant association between low birth weight (OR 1.86, 95% CI 1.0-3.2, p ≤ 0.05) and congenital anomalies (OR 2.39, 95% CI 1.4-4.0, p ≤ 0.05) with women diagnosed with hypothyroidism before pregnancy.Conclusion: We report the neonatal outcomes and spectrum of congenital anomalies of hypothyroid pregnancies diagnosed before and during conception for the first time from the region of Pakistan.Key Message: Overall, none of the neonates of hypothyroid pregnancies developed congenital hypothyroidism.Cardiovascular defects in these neonates imply extensive screening and monitoring during pregnancy.Low birth weight and congenital anomalies are associated with the timings of diagnosis of hypothyroidism in pregnancy