Grave Outcome Research Articles

Impact of first-line treatment choice on long-term outcomes of hyperthyroid Graves’ disease patients with thyrotoxic periodic paralysis

BackgroundThyrotoxic periodic paralysis (TPP) is a unique manifestation of Graves’ disease. While it is uncommon in Asian, it is extremely rare in Caucasian patients (0.1–0.2%). Previous studies suggested that TPP indicate more severity of Graves’ disease and definitive treatments should be used to prevent relapses. AimTo describe clinical features and impact of first-line treatment on long-term outcomes of TPP patients. MethodA retrospective cohort study over 35 years (1985–2019) of TPP from Graves’ disease patients was conducted. All cases were analyzed and their clinical courses were compared between those who received anti-thyroid drugs (ATD) versus radioactive iodine (RAI) as a primary treatment. None of them underwent surgery. ResultsA total of 2964 hyperthyroid Graves’ disease patients were treated and followed-up at least 3 months over the study period. TPP was identified in 63 cases (2.1%) of all patients. There were 60 males and only 3 females with age at presentation of 35.0 ± 8.2 years. TPP was the first presentation of hyperthyroid Graves’ disease in 82.5% of them. During the acute attack of TPP, all patients presented with bilateral lower limb flaccid weaknesses with median serum potassium of 2.1 mmol/L. No fatal TPP cases were found. RAI was selected as primary treatment in 27 patients (42.9%). Nearly all RAI-treated patients rendered hypothyroidism with the median RAI dose at 15 mCi. No patients who were in remission after RAI treatment developed recurrent attack of TPP. In the remaining 36 ATD-treated patients with mean follow-up time at 9.1 years, relapse was found in 10 patients (27.8%) after the drug discontinuation and 6 patients suffered recurrent TPP. Only 8 ATD-treated TPP patients (22.2%) went into remission. ConclusionsTPP is a rare complication of hyperthyroid Graves’ disease. Definitive treatment with RAI or thyroidectomy should be employed to prevent relapse and further attacks of TPP.

Management and outcomes of graves’ disease – a retrospective audit

Management and outcomes of graves’ disease – a retrospective audit

Age moderates the associations between TRAbs, free T3 and outcomes of Graves' disease patients with radioactive iodine treatment.

ObjectiveThis study aimed to explore whether age moderates the associations between TSH receptor antibodies (TRAbs) with thyroid hormones and remission in patients with Graves’ disease (GD) who undergo radioactive iodine (RAI) treatment.DesignA single‐centre retrospective study.PatientsA total of 435 eligible consecutive patients diagnosed with GD and treated with RAI therapy were included.MethodsTRAbs and thyroid hormones prior to RAI were recorded. Pearson's correlation, t tests and analysis of covariance were conducted to identify the associations between TRAbs, thyroid hormones and remission. Moderation analyses were conducted to test age as a moderator.ResultsOverall, 75.4% of the patients achieved remission with a single dose of iodine‐131. TRAb levels before RAI were positively correlated with the circulating thyroid hormones (ps < 0.001). Age moderated the association between TRAbs and free T3 (FT3) (P = .01), but did not moderate the association between TRAbs and free T4 (FT4) (P = .07). TRAb levels before RAI only significantly predicted remission status in young patients (P = .03), but not in middle‐aged (P = .36) or older patients (P = .74), after adjusting for covariates. When age was included as a continuous variable, moderation analyses revealed that the association between TRAbs and remission status was stronger in younger patients (P = .03).ConclusionsThe majority of Graves’ disease patients experienced a long‐term remission following a single dose of iodine‐131. Associations between TRAbs, FT3 and remission are moderated by age. TRAb level prior to RAI is a significant remission in younger patients, but not in middle‐aged or older patients.

The Dilemma of Renal Involvement in COVID-19: A Systematic Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), now known as coronavirus disease 2019 (COVID-19), has posed a serious threat to global health since December 2019. It has spread worldwide and is consuming healthcare resources rapidly. Published literature suggests that people with advanced age and comorbidities are affected more severely. It is crucial to uncover the underlying pathogenesis of acute kidney insufficiency in COVID-19 patients to understand better the reasoning behind the grave outcomes in these patients. In this review, we have included articles stating the prevalence and specific mortality rates of COVID-19 patients with acute kidney insufficiency. Our study included 1098 COVID-19 positive patients, of whom 66 (6%) developed acute kidney insufficiency and 62 patients died, showing a mortality rate of 94%. Patients with acute kidney insufficiency showed a more severe disease course, and these patients ended up more in intensive care units. Particular attention should be paid to those with already established kidney disease, such as chronic kidney disease, or renal transplant recipients, as these patients are already on immunosuppressive therapy. Our review focuses on the prevalence of acute kidney insufficiency in COVID-19 patients and mortality rates in this subset of patients.

Endophthalmitis after strabismus surgery: incidence and outcome in relation to age, operated eye muscle, surgical technique, scleral perforation and immune state.

PurposeIdentify risk factors for endophthalmitis after strabismus surgery (EASS) and relate these to incidence and outcome.MethodsOphthalmologists, who had operated, diagnosed or treated EASS, completed a case record form with 71 questions in six domains: Preoperative, Surgery, Perforation, Postoperative, Outcome and Experts’ opinion. To estimate the age‐specific incidence per number of strabismus operations in the Netherlands during 1994‐2013, the age distribution of Dutch cases was compared with the age‐specific rates of strabismus surgery in the Dutch Registry of Strabismus Operations and with population data. Exploratory data analysis was performed. The immune state was evaluated in six patients. Five enucleated eyes were studied histopathologically.ResultsNone of the 26 patients (27 eyes with EASS) were between 9 and 65 years old, except for one patient with retinal haemorrhage followed by endophthalmitis. In the Netherlands during 1994‐2013, the rate of EASS was approximately one per 11 000 strabismus operations, but one per 4300 for children aged 0–3 and one per 1000 for patients 65 and older. Endophthalmitis was diagnosed on postoperative day 1–4 in children aged 0–3. In all 15 children aged 0–5, the 16 affected eyes were phthisical, eviscerated or enucleated. The involved eye muscle had been recessed in 25 of 27 cases. It was a medial rectus in 15 of 16 children aged 0–6. It was a lateral (6), inferior (2) or medial (1) rectus in elderly. Scleral perforation went unnoticed in all children (no record in three) and in two of seven elderly (no record in two). Histopathology showed transscleral scarring compatible with scleral perforation in four patients but, in a two‐year‐old girl who had EASS together with a transient medial rectus palsy, the sclera underneath the former suture tract was not perforated but did contain the long posterior ciliary artery.ConclusionsEndophthalmitis after strabismus surgery (EASS) affects children and elderly, with a grave outcome in young children. It occurs after recession of the medial rectus muscle in children, and it may occur without scleral perforation. Age and perforation are key determinants that interact with other factors that determine the occurrence and fulminance of EASS.

Baseline low ALT activity is associated with increased long-term mortality after COPD exacerbations

BackgroundCOPD exacerbations have negative impact on patients’ survival. Several risk factors for grave outcomes of such exacerbations have been descried. Muscle dysfunction and mass loss were shown to impact negatively on prognosis and survival. Low activity of the enzyme ALT (Alanine amino-transferase) in the blood is a known indicator for sarcopenia and frailty, however, no previous studies addressed the association of low ALT amongst patients hospitalized due to COPD exacerbation and long-term survival.MethodsThis is a historic prospective cohort study of patients hospitalized due to acute COPD exacerbation.ResultsIncluded were 232 consecutive COPD exacerbation patients. The median time of follow-up was 34.9 months (IQR 23.13–41.73 months). During this period 104 (44.8%) patients died. All patients were grouped to quartiles according to blood ALT levels (after exclusion of cases considered to have hepatic tissue damage (ALT > 40 IU)). The risk of long-term mortality increased, in a statistically significant manner, amongst patients with low ALT values: the median survival of patients with ALT < 11 IU was 18.5 months only while the median survival for the rest of the study group was not reached. For ALT < 11 IU; 12-16 IU; 17-20 IU and > 21 IU the mortality rates were 69%; 40.9%; 36.3 and 25% respectively (p < 0.001 for comparison of lower quartile with upper three quartiles). The crude hazard ratio for mortality amongst patients with ALT levels lower than 11 IU was 2.37 (95% CI; 1.6–3.5). This increased risk of mortality remained significant after adjustment for age, weight, creatinine, albumin concentration and cardiovascular diseases (HR = 1.83; 95% CI 1.08–3.1, p < 0.05).ConclusionsLow ALT values, a biomarker of sarcopenia and frailty, are associated with poor long-term survival amongst patients hospitalized due to COPD exacerbation.

Alveolar Dead-Space Fraction and Arterial Saturation Predict Postoperative Course in Fontan Patients.

Fontan surgery, the final surgical stage in single ventricle palliation, redirects systemic venous blood into the pulmonary circulation for gas exchange. A decrease in pulmonary blood flow can lead to major complications and grave outcomes. Alveolar dead-space fraction represents the portion of inhaled air that does not participate in gas exchange and hence quantifies ventilation-perfusion abnormalities in the lung. Increased alveolar dead-space fraction has been associated with prolonged mechanical ventilation and worse outcome after congenital heart surgery. The association of alveolar dead-space fraction with clinical outcomes in patients undergoing Fontan operation has not been reported. None. A retrospective charts review of all pediatric patients who underwent Fontan surgery during June 2010-November 2018 in a tertiary-care pediatric hospital. Associations between alveolar dead-space fraction and arterial oxyhemoglobin saturation to a composite outcome (surgical or catheter-based intervention, extracorporeal membrane oxygenation use, prolonged ventilation, prolonged hospital length of stay, or death) were explored. Secondary endpoints were parameters of severity of illness, chest drainage duration, and length of stay. Of 128 patients undergoing Fontan operation, 34 met criteria for composite outcome. Alveolar dead-space fraction was significantly higher in the composite (0.33 ± 0.14) versus control (0.25 ± 0.26; p = 0.016) group. Alveolar dead-space fraction greater than or equal to 0.29 indicated a 37% increase in risk to meet composite criteria. Admission arterial oxygen saturation was significantly lower in composite versus control group (93.4% vs 97.1%; p = 0.005). Alveolar dead-space fraction was significantly associated with increased durations of mechanical ventilation, ICU length of stay, duration of thoracic drainage, and parameters of severity of illness. Alveolar dead-space fraction and arterial saturation may predict complicated postoperative course in patients undergoing the Fontan operation.

Vitamin D supplementation does not prevent the recurrence of Graves\u2019 disease

Recent literature has reported a higher prevalence of vitamin D deficiency among people with Graves’ disease. No study has examined the effect of vitamin D supplementation on the clinical outcomes of Graves’ disease. We aimed to evaluate whether daily vitamin D supplementation reduces Graves’ disease recurrence. We enrolled 210 subjects with Graves’ disease and vitamin D deficiency and followed them for at least one year after anti-thyroid drug (ATD) discontinuation. Among 210 individuals, 60 (29%) were amenable to taking vitamin D supplements, resulting in sufficient vitamin D levels (from 10.6 to 25.7 ng/mL), whereas the mean vitamin D level was 11.6 ng/mL in the 150 patients who did not take vitamin D supplements. The recurrence rate was similar in both groups (38% vs. 49%, P = 0.086). However, recurrence occurred earlier in the latter group (7 months vs. 5 months, P = 0.016). In the multivariate analysis, vitamin D levels and TSH-binding inhibitory immunoglobulin (TBII) titers at ATD discontinuation remained significant factors for recurrence. Vitamin D levels and TBII titers at ATD discontinuation exhibited a weak negative correlation (R = −0.143, P = 0.041). Vitamin D supplementation might have a protective effect against Graves’ disease recurrence with a borderline significant recurrence rate reduction.

Predictive factors for the outcomes of Graves' disease patients with radioactive iodine (131I) treatment.

Although radioactive iodine (131I) treatment (RIT) is recommended as the preferred option for patients with Graves’ disease (GD), the predictive factors for its clinical outcomes are still unclear. In the present study, we aim to investigate the factors influencing the success rate of RIT treatment on primary GD with a calculated dose approach. The thyroid function (hyperthyroidism, euthyroidism or hypothyroidism) was evaluated at least 1 year after RIT, and its relationship with presenting clinical characteristics and pre-RIT parameters was analyzed in 45 patients retrospectively. After RIT, the remission rate was 62.2%, including 13 euthyroidism cases (28.9%) and 15 hypothyroidism cases (33.3%). We found no significant association between the types of thyroid function and age, gender, the 3-h radioactive iodine uptake (RAIU) prior to RIT, or radioactive iodine (131I) dosage. However, a variable 24-h RAIU > 46.31% was found associated with the success rate of RIT. The present study implied that a calculated dose approach for GD is effective, but high failure rates are expected in patients presenting poor 24-h RAIU, particularly those with 24-h RAIU below 46.31%.

Emergency Care for Cancer Patients during Covid-19

Presently world is fighting through worldwide epidemic of coronavirus virus 2019 (COVID-19). At this period of indecision, oncologists are stressed toward deliver suitable maintenance to cancer patients. They have toward weigh danger and benefit of charitable cancer action vs chances of receiving them diseased by COVID-19. As cancer patients are immunocompromised and there are high probabilities of contact throughout hospital appointments and if they become diseased, consequence can be fatal. So, through the column of this manuscript, we would like toward deliver basic guideline in organization of cancer patients throughout COVID-19 epidemic. The world is presently aggressive against the deadly coronavirus disease 2019 (COVID-19). Globally, the number of people infected and with grave outcomes is increasing exponentially daily. During this time of pandemic, cancer patients are highly susceptible, as they are severely immunocompromised due to both their cancer and its treatment. Many of them are aged and visit medical facilities regularly, which further increases their chance of contact through infected people. Lengthways with this, hospitals are over capacity with COVID-19 patients and most outpatient services are closed to control disease transmission, so it is even extra problematic for cancer patients to seek appropriate medical care. This further enhances anxiety and confusion among cancer patients as they deal with the double blow of cancer and COVID-19. Along with cancer patients, oncologists are also facing challenges, as no one has experience with this novel disease and there remain many unrequited queries concerning suitable care of cancer patients. So, finished the column of this article, we would like to deliver basic guideline in management of cancer patients during this COVID-19 pandemic.

Atypical Hemolytic Uremic Syndrome After Kidney Transplantation: Lessons Learned From the Good, the Bad, and the Ugly. A Case Series With Literature Review

Atypical hemolytic uremic syndrome (aHUS) after kidney transplantation is rare and carries a grave outcome. We present a single-center experience of all aHUS cases since the program’s inception. Six patients were diagnosed with aHUS, all after kidney transplants, except for 1 patient. All had nonreactive crossmatches. Delayed graft function (DGF) occurred in 2 patients. Five patients developed aHUS after transplant; 4 (80%) of these patients manifested aHUS ≤ 14 days. All were confirmed by allograft biopsy. Genetic testing was abnormal in all patients except for 1 patient. Actual patient and graft survival during the first year was 100% and 83.3%, respectively. A single graft was lost early in the study secondary to aHUS (eculizumab was not used in the treatment process). Prophylactic and therapeutic use of eculizumab salvaged all other cases. At 1 year, mean creatinine level was 1.9 mg/dL (range, 1.3-2.5). After 6 months of eculizumab treatment (halted in 2 cases) 1 patient had recurrence 2 months later and eculizumab was restarted. However, graft function continued to worsen, and the graft was ultimately lost at 20 months after kidney transplantation. High index of suspicion, prompt diagnosis, and utilization of eculizumab are key to successful salvage of allografts in cases of aHUS after kidney transplantation. aHUS can be prevented by prophylactic use of eculizumab. It still needs to be determined when and if eculizumab therapy can be safely discontinued.

Effect of Graves' disease on the prognosis of differentiated thyroid carcinoma: a meta-analysis.

Several studies have reported different findings on the prognosis of differentiated thyroid carcinoma combined with Graves' disease. To assess the effect of Graves' disease on differentiated thyroid carcinoma, a meta-analysis was undertaken. PubMed, OVID and the Cochrane Library were systematically searched for trials published prior to Oct. 2018. Studies containing data on the outcomes of Graves' disease with differentiated thyroid carcinoma were included. Summary estimates of the prevalence of recurrence/disease progression/persistence and mortality as well as odds ratios and weighted mean differences were calculated with a random-effects model. Of the 916 related articles found, 13 fulfilled the inclusion criteria. The recurrence/disease progression/persistent rate was not significantly different between the Graves' disease group and the non-Graves' disease group (P = 0.86). However, the analysis of three studies with K-M curves or HRs showed that there was a significant difference between the two groups (P = 0.04). Subgroup analysis showed that the contradictory results could be due to the location/race assessed in the studies. Graves' disease almost acted as a risk factor (OR = 1.77, 95%C.I. = 0.99-3.16) for differentiated thyroid carcinoma in European studies. When heterogeneous studies were excluded, the analyses show that GD was a risk factor for recurrence/disease progression/persistence (P = 0.03, OR = 1.75, 95%C.I. = 1.04-2.95). The overall mortality rate was significantly higher in the Graves' disease group than in the non-Graves' disease group (P = 0.02, OR = 2.93, 95%C.I. = 1.17-7.37). Graves' disease acts as a risk factor for the prognosis of differentiated thyroid carcinoma. The recurrence/disease progression/persistent rate may be affected by TSAbs in a specific location/race and with a genetic immunization background. However, the histotypes and subtypes may play an important role in mortality rate.

P5012Ten-year trends and outcomes in cardiogenic shock related to first-time acute myocardial infarction: a nationwide population-based cohort study

Abstract Introduction Despite declining incidence and mortality for acute myocardial infarction, cardiogenic shock remains a severe complication with poor in-hospital prognosis. Little is known about the temporal trends in hospitalization with acute myocardial infarction-related cardiogenic shock (AMI-CS) and the long-term prognosis. Purpose We aimed to investigate the hospitalization with first-time AMI-CS and subsequent 1-year mortality. Methods In this nationwide Danish cohort study we identified from 2005 through 2015 patients with first-time acute myocardial infarction and compared those with and without cardiogenic shock (defined by either an ICD-10 diagnosis code with cardiogenic shock and/or procedure code with inotropes or vasopressors). Patient characteristics and 1-year mortality were compared between groups using Kaplan-Meier plots and multivariable Cox regression analysis. Results We included 96,030 patients with acute myocardial infarction of whom 5.4% had cardiogenic shock. Median age was 69.7 years (IQR 59.0–80.1) and 37.5% were female among those without cardiogenic shock and 70.2 years (IQR 61.4–78.1) and 33.0% were female in those with cardiogenic shock. We observed no change in hospitalization with cardiogenic shock during the study period (5.45% in 2006 vs 5.54% for 2016, P for difference 0.6). One-year mortality was higher among those with cardiogenic shock relative those without (See Figure). Crude 1-year mortality risk associated with AMI decreased over time from 23.4% in 2006 vs 11.5% in 2016 (p for difference &lt;0.0001) and this was consistent for AMI patients without CS (21.4% in 2006 vs 9.4% in 2016, p&lt;0.0001) and patients with AMI-CS (58.1% in 2006 vs 46.2% in 2016, p&lt;0.0001). When comparing patients with AMI-CS to those without in multivariable analysis, AMI-CS was associated with a 1-year mortality hazard ratio of 5.38 (95% CI 5.17–6.61)). Cumulative 1-year mortality among patien Conclusion In a large population-based setting, this study suggests that the hospitalization for first-time AMI-CS was stable from 2005 through 2015, while mortality improved with time. However, the grave outcome related to AMI-CS remains with a 5-times higher mortality compared to AMI patients without CS. Acknowledgement/Funding Rigshospitalets Research Fund

Knowledge, Attitude and Practices (KAP) related to Pandu Roga (Iron Deficiency Anaemia) among Adolescent Girls attending Ayurveda Tertiary Care Hospital and Nearby Schools - A Survey

Introduction: According to Ayurveda, depletion of Rasa and Rakta Dhatu results in yellowish-white discoloration of body known as Pandu Roga. Its features resemble with IDA (Iron Deficiency Anaemia). It is very common among female adolescents. UNICEF observed that more than half of population of adolescent girls in India are anemic. Lack of knowledge is one of the most significant reason for nutritional problems like anaemia. Aim: To evaluate the level of knowledge, attitude and practices regarding Pandu Roga (Iron Deficiency Anaemia) among female adolescents. Material and Methods: In this study 200 adolescent girls aged between 10 to 16 years visiting Kaumarabhritya OPD, A.I.I.A hospital and nearby government schools were assessed on the basis of a ‘Knowledge, Attitude and Practices (KAP) Questionnaire’ regarding Pandu Roga (IDA). Result: It was found that most of the screened adolescents had poor knowledge of Pandu Roga (IDA), its causes, prevention and management. Discussion: Pandu Roga (IDA) is a dangerous health problem globally, if not attended in time may result into grave outcomes, hence emphasis should be made on its prevention in addition to the cure. Conclusion: There is a need to focus on various health education programs for prevention of nutritional problems like IDA.

Fingolimod Improves the Outcome of Experimental Graves' Disease and Associated Orbitopathy by Modulating the Autoimmune Response to the Thyroid-Stimulating Hormone Receptor.

Graves' disease (GD) and Graves' orbitopathy are associated with stimulating thyrotropin receptor (TSHR) autoantibodies and autoreactive T cells. Recent in vitro studies suggested that sphingosine-1-phosphate (S1P) signaling is involved in the pathogenesis of orbitopathy. In this study, we explored the immune modulatory potential of S1P receptor antagonist fingolimod in a murine model for GD. Fingolimod was orally administered preventively during disease onset or therapeutically after disease onset. Administration of fingolimod during disease onset completely prevented the formation of TSHR-stimulating autoantibodies. Intervention after disease onset rarely reduced TSHR-stimulating autoantibodies and blocking autoantibodies were induced in some animals. Consequently, autoimmune hyperthyroidism characterized by elevated serum thyroxin levels, hyperplastic thyroid morphology accompanied by T cell infiltration, weight gain, enhanced body temperature, and tachycardia did not manifest preventively and showed milder manifestation in therapeutically treated animals. Importantly, examination of orbital tissue showed significant amelioration of orbitopathy manifestations through reduction of T cell infiltration, adipogenesis, and hyaluronan deposition. Autoimmune hyperthyroidism and orbitopathy were accompanied by changes in peripheral and splenic T cell proportions with high CD3+, CD4+, and CD8+ T cells. Activated T cells CD4+CD25+ were elevated whereas regulatory T cells CD4+Foxp3+ cells remained unchanged in spleens. Fingolimod decreased elevated T cell levels and increased CD4+CD25+Foxp3+ regulatory T cell populations. Analysis of total disease outcome revealed that treatment during disease onset protected animals against autoimmune hyperthyroidism and orbitopathy. Of note, therapeutic intervention after disease onset suppressed disease in half of the animals and in the other half disease remained at mild stages. The results of this study support a clinical trial to investigate the immunologic and clinical benefits of early treatment with S1P-based drugs in GD.

Characteristics and outcomes of HFpEF with declining ejection fraction.

Some patients with heart failure with preserved ejection fraction (HFpEF) experience declining of left-ventricular ejection fraction (LVEF) during follow-up. We aim to investigate the characteristics and outcomes of patients with HF with declining ejection fraction (HFdEF). We analyzed a prospective, nationwide multicenter cohort with consecutive patients with acute HF enrolled from March 2011 to December 2014. HFpEF was defined as LVEF ≥ 50% at index admission. After 1year, HFpEF patients were further classified as HFdEF (LVEF ≥ 50% at admission and < 50% at 1year), and persistent HFpEF (LVEF ≥ 50% both at admission and 1year). Primary outcome was 4-year all-cause mortality according to HF type from HFdEF diagnosis. Of patients with HFpEF, 426 (90.4%) were diagnosed as having persistent HFpEF and 45 (9.6%) as having HFdEF. Natriuretic peptide level was an independent predictor of HFdEF (natriuretic peptide level > median: odds ratio: 3.20, 95% confidence interval [CI]: 1.42-7.25, P = 0.005). During 4-year follow-up, patients with HFdEF had higher mortality than those with persistent HFpEF (Log-rank P < 0.001). After adjustment, HFdEF was associated with an almost twofold increased risk for mortality (hazard ratio 1.82, 95% CI 1.13-2.96, P = 0.015). The use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists was not associated with improved prognosis of patients with HFdEF. HFdEF is a distinct HF type with grave outcomes. Further investigations that focus on HFdEF are warranted to better understand and develop treatment strategies for these high-risk patients. ClinicalTrial.gov identifier: NCT01389843. URL: https://clinicaltrials.gov/ct2/show/NCT01389843.

Risk Factors of Diabetic Foot Amputation in Pakistani Type II Diabetes Individuals

IntroductionThe major grave outcome of diabetic complications is the amputation of lower limb extremities. Recurrent foot infections, trauma, ischemia, and peripheral neuropathy play a crucial role in predicting foot amputation. The aim of this study is to identify the risk factors of diabetic foot amputations in Pakistani patients.MethodsPatients admitted with diabetic foot-related complications were followed throughout their hospital stay. Their sociodemographic and disease-related characteristics were recorded. Patients who were advised foot amputation were taken as group A, and patients who were managed conservatively were termed as group B. Their characteristics were then compared.ResultsOut of 226 study participants, there were 51 (22.5%) patients in group A who were advised foot amputation. There were more men in group A as compared to group B (72.5% vs. 30.8%; p<0.00001). Group A also had a longer duration of diabetes (15.23 ± 8.52 years vs. 11.98 ± 9.69; p=0.03). Group B included more patients taking insulin therapy (44.5% vs. 37.3%; p=0.002). All three risk factors of atherosclerosis - smoking, hyperlipidemia, and hypertension - were significantly associated with group A (p≤0.05). This coexistence of diabetic nephropathy and retinopathy were more common in group A (p≤0.05).ConclusionThe incidence of foot amputation in diabetic patients is high. Crucial risk factors include male gender, smoking, hyperlipidemia, hypertension, cardiac history, and the coexistence of diabetic nephropathy and retinopathy.

The Society of Behavioral Medicine supports an increase in funding for Medication-Assisted-Treatment (MAT) to address the opioid crisis.

Opioid use has become an epidemic in the USA. Although there are safe uses for opioids to help manage acute pain, the effects of long-term use and any misuse of opioids can have grave outcomes, including death. To provide an empirically based "ask" for increased funding from the federal government to increase the reimbursement for and the integration of the behavioral component of Medication-Assisted-Treatment (MAT) for opioid use disorders, current policy was reviewed and important gaps in funding and treatment fidelity were identified. Current barriers to treatment include a dearth of treatment programs and a greater emphasis on and reimbursement for the pharmacological component of MAT only, leaving the behavioral component largely underfunded. We recommend additional funding to (a) increase the availability of and coverage for MAT that combines both pharmacological and behavioral components and (b) support the scientific inquiry into the factors that contribute to, maintain, and exacerbate opioid-related issues. We also recommend declaring the opioid epidemic a national emergency and not just a public health emergency, which would provide immediate access to billions of dollars in federal dollars to fund treatment programs.

CRYPTOCOCCAL meningitis in a HIV negative newly diagnosed diabetic patient: a CASE report

BackgroundThis case report emphasizes the need to recognize cryptococcus as a possible cause of meningitis in non-HIV patients in Sub-Saharan Africa and to highlight the possibility of grave outcomes due to the paradoxical immune response in diabetic patients with cryptococcus meningitis. It also highlights the need for widespread availability of amphotericin-B and flucytosine in hospitals in Sub-Saharan Africa.Case presentationA 27 year old African lady was admitted with generalized tonic clonic seizures lasting 5 to 10 min. These seizures were preceded by severe frontal headaches radiating to the occiput and neck and associated with chills, photophobia and loss of consciousness. She was tachycardic and had tongue bites on the lateral aspects of her tongue. Kernig’s and Brudzinski’s signs were positive. India ink was positive on two cerebrospinal fluid (CSF) samples. She had hyperglycemia and glucosuria as well. She was diagnosed with cryptococcal meningitis in diabetes and had a remarkable response to fluconazole monotherapy. She went home on maintenance dose of fluconazole having made full recovery. and is currently on prophylactic doses of fluconazole.ConclusionsWith the rising prevalence of diabetes in Sub-Saharan Africa, coupled with the low levels of adequate glucose control, cryptococcal meningitis should be considered in the differential diagnosis for diabetic patients presenting with chronic headache, fever and neurologic deficits.

Evolutionary Profile of Graves’ Disease in Children at Albert Royer National Children Hospital in Dakar

Graves’ disease is the most common cause of hyperthyroidism. Adequate management is an area of controversy, especially when it comes to children. The objective of our study was to assess the outcome of Graves’ disease treatment in Albert Royer Children Hospital of Dakar. This was a retrospective study conducted from 2001 to 2015, and which involved all children between 0 to 15 years of age who were being monitored in the Albert Royer National Children Hospital. The evolutionary modalities were: stability, remission, failure, relapse, lost to follow-up and death. The data were analyzed with SPSS software version 20.0. For the comparisons, the KHI 2 or Fisher test was used with a significance threshold (p < 0.05). During the study period, 88 children were enrolled. The average age was 8.6 years [ranging from 8 months to 15 years]. The consultation delay was 11.36 months. In our study, 61.4% of the patients were regular in the follow-up, the observance was good in 40.9% of the cases and 19 patients (21.6%) were lost to follow-up. Clinical courses of 69 children after treatment with Carbimazole for 37 months were promising in 21 cases (30.43%), with 17 cases of remission (24.63%) and 4 cases of stability (5.8%). Age older than 10, the initial ATD dose greater than 1 mg/kg/day and the initial free T4 lower than 50 pmol/l were significantly associated with remission with a p value of 0.01; 0.024 and 0.004.