Feto-Maternal Outcomes and Treatment Compliance in Metformin Versus Insulin-Treated Gestational Diabetic and Non-Diabetic Patients at the Rehman Medical Institute, Peshawar

Introduction Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The diagnosis is made on the basis of the oral glucose tolerance test (OGTT) which according to the guidelines of ACOG regards a blood glucose level higher than 190mg/dL after the one-hour test as the criteria for GDM. The first-line agent for GDM is insulin injections; however, it has high costs and also causes its own feto-maternal complications which can include weight gain and polyhydramnios. On the contrary, metformin has fewer complications, is cheaper, and is emerging as a better alternative for the first-line agent for the treatment of diabetes mellitus type 2. GDM had a prevalence of 11.8% in the year 2018 in all trimesters of pregnancy in Pakistan. This study was thus conducted to determine the feto-maternal outcomes of non-GDM and GDM patients on insulin, metformin, and combined treatment respectively admitted to gynecology ward Rehman Medical Institute (RMI) Khyber Pakhtunkhwa, Pakistan in the year 2019. Objectives To determine the feto-maternal outcomes in patients of GDM on metformin treatment and the feto-maternal outcomes in patients of GDM on insulin treatment and to compare the feto-maternal outcomes of mothers with GDM to those without GDM. Methodology This is a retrospective study conducted from January to April 2020 on patients of gestational diabetes mellitus undergoing either metformin, insulin, or both therapies admitted to the gynecology ward, Rehman Medical Institute (RMI). After getting ethical approval from the institutional ethical approval board, data were collected for the entire year of 2019 on the basis of proforma with the variables: demographic data, glycemic control (via OGTT), mode of labor, primary open-angle glaucoma (POAG), and feto-maternal outcomes. Data was entered and analyzed via SPSS version 21.0 (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY) and the data were run through various tests including descriptive statistics, cross-tabulations, and chi-square. Results were formulated on the basis of these reports which were then presented in the form of graphs and tables. Results Out of 150 mothers who were admitted for delivery at the gynecology ward, 123 (82.0%) women were 30-40 years of age. Non-gestational diabetics patients were 78 (52%) whereas gestational diabetic mothers were 72 (48%); within these GDM-positive mothers 44 (61.1%) were on metformin, 21 (29.1%) were on insulin and seven (9.7%) were on combined treatment. Among modes of delivery, C-section was the most common (113 [76%]), mostly in non-GDM mothers (95 [45.1%]) followed by those on metformin treatment (36 [31.8%]). Considering fetal outcomes there was a significant association between NICU admissions, neonatal jaundice, and breech presentation with insulin-treated mothers (p=0.06, p=0.003, p=0.004, respectively CI=95%). Among maternal outcomes, there was a significant association between pregnancy-induced hypertension (PIH) and insulin-treated patients (p=0.02 CI=95%), premature rupture of membranes (PROM), and metformin-treated patients (p=0.01 CI=95%) whereas eclampsia was significantly associated with mothers not having GDM (p=0.001 CI=95%). Conclusion Based on this preliminary data and considering feto-maternal outcomes, metformin appears to be a safer drug as compared to insulin in the treatment of GDM with more compliance.

Phagocytic killing and antibody response during the first year after tetravalent meningococcal vaccine in complement-deficient and in normal individuals

Seven individuals with late complement component (LCC) deficiency and seven control subjects were vaccinated with tetravalent meningococcal vaccine. The response to vaccination was evaluated by measuring the antibody titer and the phagocyte killing of the bacteria, before, 5-7 weeks, and 12-14 months after vaccination. Prior to vaccination, no phagocytic killing and a low titer of antibody was found in the LCC-deficient group and a low killing (mean of 40-58%, according to the serogroup) in normal controls. The phagocytic killing increased significantly 5-7 weeks after vaccination. However, while in normal controls the phagocytic killing was close to 100% after 5-7 weeks and decreased only slightly during the first year, the mean killing of the various meningococcal subgroups in LCC-deficient individuals was 70-89% and dropped to only 53-71% one year after vaccination. Six weeks after vaccination the mean antimeningococcal antibody titer increased similarly in the sera of LCC-deficient patients and controls. One year after vaccination the controls maintained the high concentration, while the LCC-deficient patients had tendency toward a decrease. In addition, the interpersonal variability of the antibody concentration, both in LCC-deficient individuals and in normal controls, was much higher than the phagocytic killing, with only a very mild increase in some individuals. Thus, it is possible that in spite of adequate increase of antimeningococcal antibody titer after vaccination of LCC-deficient individuals their immunity against the bacteria may not be optimal. Our data show also that phagocytic killing of meningococci is probably a more consistent assay than antibody titer levels for antimeningococcal immunity, especially in LCC-deficient patients.

Hand metastasis from renal cell carcinoma with no bone involvement

Hand metastases account for 0.1% of all metastases and most of them involve primarily the bones. A case of a metastasis from renal cell carcinoma to the distal segment of the little finger with no bone involvement is described. In view of the fact that the kidneys are the origin of only 10% of hand metastases, such a case is extremely rare.

Compartmental syndrome due to high velocity missile injury of the calf: use of immediate mesh skin grafting

Two patients with high velocity missile injury to the soft tissues of the calf without major fractures are presented. Both of them developed compartmental syndrome and were treated by debridement, fasciotomy, and immediate mesh split thickness skin graft. The mechanisms of such injury and the advantage of immediate skin grafting are discussed.

Skin injury following contact with a complex amine

Eight patients with skin damage due to contact with an amine are described. The material is used in the potash industry under the commercial name of Armine to prevent bosselation. Although it is considered to be a strong base, no deep burns were encountered. The reaction to this material initially resembled a dermatitis; later the wound developed the typical appearance of a burn. In addition to the common conservative treatment, antihistamine drugs were used. When a true allergic reaction was suspected steroids were added to the regimen.

Burn hazard from cupping--an ancient universal medication still in practice

The ancient universal medication of cupping is still practised by devoted believers and people who, for various reasons, have lost faith in other more modern modalities of medical treatment. Faulty technique in producing the vacuum in the cups was the aetiology of the burns in several patients. The history, theories and indications for cupping are reviewed.

Burns during pregnancy: our experience

Although few women sustain thermal injuries during pregnancy, when pregnancy is complicated by thermal injury a clear management scheme plus a team approach is needed to provide optimal care both to the foetus and mother. The clinical course of eight pregnant women treated in our burn unit is presented. The relationship between the burn area, gestational age at treatment and prognosis is analysed. Active surgical treatment is advocated.

Cerebral arteriovenous malformation: papilledema as a presenting sign

Papilledema as a presenting sign of arteriovenous malformation without evidence of a space-occupying lesion or hydrocephalus is an unusual finding. The pathogenetic theory that seems to explain such cases is the increase of cerebral blood volume leading to intracranial hypertension, thus resulting in papilledema. We present the case of a 31-year-old woman complaining of headaches, with papilledema as the only objective finding. Computed tomography scan and right carotid angiography demonstrated a right mid rolandic arteriovenous malformation. The lesion was totally removed under intraoperative angiographic control.

Adjuvant therapy for Dukes C adenocarcinoma of colon

Forty-two patients with adenocarcinoma of the colon, who received surgery between 1975 and 1978 and were to found to have pericolonic fat infiltration and lymph node metastases, were analyzed for disease free period and overall survival. Twenty-one patients had received post-operative X ray therapy, and post-X ray therapy intravenous 5-Fluorouracil adjuvant therapy. Twenty-one patients, matched by age, sex, ethnic origin and site of disease were untreated. The 5 year survival rate for the treated group was 65% compared with 36% for the control group (P greater than 0.2). At 5 years 55% of the treated group were disease free but only 12% of the control group remained disease free (P = 0.04). The significance of this work needs to be established by a randomized and prospectively controlled clinical trial.

Effect of colchicine on immunoregulatory abnormalities in familial Mediterranean fever

The effect of colchicine on immunoregulatory T lymphocytes in children with familial Mediterranean fever (FMF) was studied. Concanavalin A (Con A)-induced suppressor cell function was significantly (P less than 0.0001) decreased in five untreated FMF patients (15 +/- 3%, mean +/- s.e.) as compared to six age matched paediatric controls (46 +/- 3%) and eight healthy adults (49 +/- 4%). When the five untreated FMF patients' mononuclear cells were pre-incubated in vitro with Con A plus 10(-5) M colchicine, their suppressor cell function was significantly increased (52 +/- 10%, P less than 0.01). Similarly, oral colchicine treatment (0.5 mg twice daily) significantly (P = 0.02) increased the five FMF patients' Con A-induced suppressor cell function to levels (34 +/- 6%) that were not significantly (P greater than 0.05) different than the paediatric controls or the healthy adults. The percentage of OKT8+ cells (but not OKT3+ or OKT4+ cells) was significantly (P less than 0.0001) decreased in 10 untreated FMF patients (16.0 +/- 0.9) as compared to 10 paediatric controls (27.6 +/- 2) or 10 healthy adults (25.7 +/- 0.6). The 10 untreated FMF patients had a significant (P less than 0.002) increase in the OKT4/OKT8 ratio (2.41 +/- 0.13) as compared to 10 FMF patients treated with 0.5 mg twice daily of colchicine (1.81 +/- 0.08), 10 pediatric controls (1.47 +/- 0.2), or 10 healthy adults (1.78 +/- 0.11). Colchicine appears to have corrected the FMF patients' elevated OKT4/OKT8 ratio by both decreasing the percentage of OKT4+ cells and increasing (but only partially correcting) the percentage of OKT8+ cells. Thus FMF patients have a suppressor cell deficiency in which colchicine treatment corrects their deficiency of Con A-induced suppressor cell function and their elevated OKT4/OKT8 ratio. This raises the possibility that colchicine might be potentially useful as an immunomodulating drug in treating patients with autoimmune or allergic diseases associated with a suppressor cell deficiency.