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.

Efficacy and Tolerability of Semaglutide in Patients With Type-2 Diabetes Mellitus: Experience of a Tertiary Care Hospital, Pakistan

Background

Semaglutide, a Glucagon-like peptide 1 (GLP-1) is highly effective as an anti-diabetic medication along with additional benefits of significant reduction in cardiovascular events and weight.

Objectives

There is a lack of reliable evidence confirming the benefits of Semaglutide in the Pakistani cohort. Our study aims to ascertain the efficacy of Semaglutide in the Pakistani cohort and patient satisfaction.

Methods

An ambi-directional cohort study was conducted from August 2022 to January 2023 at The Aga Khan University Hospital, Karachi, Pakistan. A chart review was done for all patients with Type 2 diabetes who were prescribed Semaglutide, and baseline data was recorded. Patients were followed prospectively in the endocrinology clinics after at least 3 months for the change in HbA1c, BMI, adverse effects profile, treatment satisfaction questionnaire for medications (TSQM-9) and medication effect score. Mean + STD or median with IQR were computed for continuous data, while categorical variables and percentages were measured. The association between variables was assessed by applying the chi-square test.

Results

A total of 112 patients were recruited who took the medication for at least 3 months. The mean age of the patients was 50.9 ± 10.5 years with 51.2% females. The mean difference in weight, body mass index, fasting blood glucose, HbA1c, and medication effect score were decreasing from baseline to follow-up (-4.0 kg, -1.5 kg/m2, -23.1 mg/dl, -1.2%, -0.4) respectively. A decrease in appetite was reported in 72.7% of the participants. The major adverse effects observed were dyspepsia (21.4%) followed by nausea (20.5%) and constipation (19.6%). Medication was discontinued in 9.8% of patients due to gastrointestinal side effects. The majority (72.3%) of patients were satisfied with their medication.

Conclusion

Semaglutide is effective in reducing HbA1c and weight in Pakistani population with measurable tolerability and patient satisfaction.

Cost-effectiveness of a multicomponent quality improvement care model for diabetes in South Asia: The CARRS randomized clinical trial

OBJECTIVES

To assess the cost-effectiveness of a multicomponent strategy versus usual care in people with type 2 diabetes in South Asia.

DESIGN

Economic evaluation from healthcare system and societal perspectives.

SETTING

Ten diverse urban clinics in India and Pakistan.

PARTICIPANTS

1146 people with type 2 diabetes (575 in the intervention group and 571 in the usual care group) with mean age of 54.2 years, median diabetes duration: 7 years and mean HbA1c: 9.9% (85 mmol/mol) at baseline.

INTERVENTION

Multicomponent strategy comprising decision-supported electronic health records and non-physician care coordinator. Control group received usual care.

OUTCOME MEASURES

Incremental cost-effectiveness ratios (ICERs) per unit achievement in multiple risk factor control (HbA1c <7% (53 mmol/mol) and SBP <130/80 mmHg or LDLc <2.58 mmol/L (100 mg/dL)), ICERs per unit reduction in HbA1c, 5-mmHg unit reductions in systolic BP, 10-unit reductions in LDLc (mg/dl) (considered as clinically relevant) and ICER per quality-adjusted life years (QALYs) gained. ICERs were reported in 2020 purchasing power parity-adjusted international dollars (INT$). The probability of ICERs being cost-effective was considered depending on the willingness to pay (WTP) values as a share of GDP per capita for India (Int$ 7041.4) and Pakistan (Int$ 4847.6).

RESULTS

Compared to usual care, the annual incremental costs per person for intervention group were Int$ 1061.9 from a health system perspective and Int$ 1093.6 from a societal perspective. The ICER was Int$ 10,874.6 per increase in multiple risk factor control, $2588.1 per one percentage point reduction in the HbA1c, and $1744.6 per 5 unit reduction in SBP (mmHg), and $1271 per 10 unit reduction in LDLc (mg/dl). The ICER per QALY gained was $33,399.6 from a societal perspective.

CONCLUSIONS

In a trial setting in South Asia, a multicomponent strategy for diabetes care resulted in better multiple risk factor control at higher costs and may be cost-effective depending on the willingness to pay threshold with substantial uncertainty around cost-effectiveness for QALYs gained in the short term (2.5 years). Future research needs to confirm the long-term cost-effectiveness of intensive multifactorial intervention for diabetes care in diverse healthcare settings in LMICs.

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.

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.

Follicular Thyroid Carcinoma in a Developing Country: A 10-Year Retrospective Study

Background The most common endocrine tumor is thyroid cancer. Follicular thyroid carcinoma (FTC) accounts for 5-10% of all thyroid cancers. Patients with FTC frequently present with more advanced diseases and a higher occurrence of distant metastases because of the propensity of vascular invasion. FTC is mainly treated with surgery while radioactive iodine (RAI) therapy is the main adjuvant therapy according to the American Thyroid Association guidelines. Methodology This was a retrospective observational study of FTC patients aged 18 and above conducted at a tertiary care hospital in Karachi from January 01, 2010 to December 31, 2019. Results A total of 404 patients with thyroid carcinoma were sorted, of which 40 (10.1%) were FTC cases. Overall, 50% of the patients were in the age group of 41-60 years, and the female-to-male ratio was 1.5:1. The majority of patients (60%) presented with neck swelling, followed by bone and lung metastasis in 20% and compressive symptoms in another 20%. On fine needle aspiration cytology (FNAC), 50% had Bethesda category III-IV nodules while 10% had Bethesda category II. Overall, 50% had a total thyroidectomy while 50% had a lobectomy followed by a completion thyroidectomy. On histopathology, 23 (57.5%) patients had minimally invasive FTC while 17 (42.5%) had widely invasive FTC. A total of 17 (42.5%) patients had received RAI 30-100 mCi while 10 (25%) received more than 100 mCi. Conclusions FTC can present with both local or metastatic symptoms. The atypical presentation of metastatic FTC should be considered, diagnosed, and managed early to limit mortality and morbidity. Ultrasound is the best diagnostic investigation of choice followed by FNAC. Surgery is the mainstay of treatment and should be followed by RAI in select cases. Thus, understanding the trend of FTC and proper planning and utilization of the resources will help developing countries in effectively treating the FTC.

Prevalence of Abnormal Glucose Metabolism in Acromegaly & Impact of Treatment Modalities on Glucose Metabolism

Objective: To determine the frequency of diabetes mellitus impaired glucose tolerance and impaired fasting glucose in Pakistani patients with acromegaly and to establish the impact of the intervention (surgery/ medical) on glucose metabolism.

Methods: Eighty-nine patients fulfilling the endocrine society criteria for acromegaly diagnosis were included. A data of baseline, growth hormone (GH), Insulin-like growth factor-1 (IGF-1) level, Hemoglobin A1C (HbA1C), fasting blood glucose (FBG), and random blood glucose (RBS) levels were reviewed before and after the intervention (surgery/medical therapy). Normal glucose tolerance (NGT), impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and diabetes mellitus (DM) were defined based on the 2003 ADA criteria. Patients were grouped into normoglycemic (NGT) and dysglycemic (IFG, IGT, and DM) based on FBS, RBS, and HbA1C.

Results: Major risk factors for dysglycemia included age (15-45 years), male sex (33.70%), obesity (45.7%), and macroadenoma (76%). Both mean GH levels (58.29 vs. 54.36 ng/dl) and IGF-1 levels (862.98 vs. 824.32 ng/dl) were higher among the normoglycemic than dysglycemia. Pre-surgery, NGT, IFG, IGT, IFG, and IGT combined and DM were found in 48.31, 5.61, 1.1, 5.61, and 39.32 % of the subjects, respectively. Post-surgery, HbA1C improved in 79.5%, deteriorated in 6.8%, and remained the same in 13.6%. Similarly, it improved in 67.4.7% post-medical therapy. Both FBS and RBS improved post-surgery and medical therapy. Further, the number of anti-diabetic drugs used also decreased post-surgery.

Conclusion: Dysglycemia is more common among patients with acromegaly as compared to the general population and tends to be poorly controlled in untreated acromegaly. Glycemic control improves significantly after the surgery and medical therapy.

Keywords: Acromegaly, Diabetes Mellitus, Transsphenoidal surgery

Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial

AIMS

To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care.

METHODS

Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA_1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA_1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol.

RESULTS

Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA_1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively].

CONCLUSIONS

The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

Meta-Analysis of Inclisiran for the Treatment of Hypercholesterolemia

Statin therapy is the gold standard for hypercholesterolemia. However, a significant number of patients cannot achieve their target low-density lipoprotein (LDL) levels despite a maximal dose of statin therapy, and some cannot tolerate statins at all. Approval of proprotein convertase subtilisin/kexin type 9 inhibitors has been revolutionary for those patients. However, the need for frequent injections limits patient compliance with their use. Recently, a twice-yearly injection of inclisiran, a small interfering RNA, has been shown to inhibit hepatic synthesis of proprotein convertase subtilisin/kexin type 9. However, patient randomized clinical trial has been underpowered for clinical end points, necessitating a meta-analysis of those trials. The weighted mean difference was used to describe continuous variables, and pooled risk ratios, calculated using a random effects model, were used to describe discrete variables. Data from 3 randomized clinical trials comprising 3,660 patients showed that inclisiran decreased LDL cholesterol levels by 51% (95% Confidence Interval, 48 to 53%; p < 0.001) compared with placebo. It was associated with a 24% lower major adverse cardiovascular events rate (risk ratios = 0.76; 95% Confidence Interval, 0.61 to 0.92). It also significantly decreased total cholesterol by 37%, apolipoprotein B by 41%, and non high-density lipoprotein (HDL) cholesterol by 45% (all p < 0.001). No differences were found in adverse events, abnormalities in liver function tests, or creatine kinase levels between the treatment strategies. However, a mild injection site reaction occurred more frequently in the inclisiran group. In conclusions, in patients with hypercholesterolemia, inclisiran decreased LDL level by 51% without significant adverse effects. Additionally, it was associated with a lower major adverse cardiovascular event rate.

Hypopituitarism other than sellar and parasellar tumors or traumatic brain injury assessed in a tertiary hospital

Objective:

Data regarding the etiology, clinical and biochemical patterns in hypopituitarism is scant for Pakistan. We describe the characteristics of patients with hypopituitarism other than sellar and parasellar tumors or traumatic brain injury from a tertiary care center in Pakistan.

Methods:

We conducted a retrospective descriptive study in the Aga Khan University Hospital, Karachi, Pakistan. We studied all patients presenting with hypopituitarism, between January 2004 and December 2013. Clinical, hormonal and imaging data pertinent to the study was collected according to inclusion criteria.

Results:

Forty-two patients presented to the endocrinology clinics at the Aga Khan University Hospital during the study period. Thirty-seven patients (88.1%) were females. Mean age ± standard deviation of the participants was 53.8 ± 14.7 years. Sixteen patients had secondary infertility and all were females; a majority of patients in this group had Sheehan’s syndrome (n=8) followed by empty sella syndrome (n=3), partial empty sella syndrome (n=2), idiopathic cause (n=2) and tuberculoma (n=1). Eighteen females (48.6%) reported inability to lactate.

Conclusions:

Non-traumatic hypopituitarism was more common in women, with Sheehan syndrome being the most common cause of hypopituitarism in our study (35.7%). Secondary hypothyroidism was the most common hormonal deficiency. The most commonly reported symptom was weakness.

Rationale and protocol for estimating the economic value of a multicomponent quality improvement strategy for diabetes care in South Asia

BACKGROUND

Economic dimensions of implementing quality improvement for diabetes care are understudied worldwide. We describe the economic evaluation protocol within a randomised controlled trial that tested a multi-component quality improvement (QI) strategy for individuals with poorly-controlled type 2 diabetes in South Asia.

METHODS/DESIGN

This economic evaluation of the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) randomised trial involved 1146 people with poorly-controlled type 2 diabetes receiving care at 10 diverse diabetes clinics across India and Pakistan. The economic evaluation comprises both a within-trial cost-effectiveness analysis (mean 2.5 years follow up) and a microsimulation model-based cost-utility analysis (life-time horizon). Effectiveness measures include multiple risk factor control (achieving HbA1c < 7% and blood pressure < 130/80 mmHg and/or LDL-cholesterol< 100 mg/dl), and patient reported outcomes including quality adjusted life years (QALYs) measured by EQ-5D-3 L, hospitalizations, and diabetes related complications at the trial end. Cost measures include direct medical and non-medical costs relevant to outpatient care (consultation fee, medicines, laboratory tests, supplies, food, and escort/accompanying person costs, transport) and inpatient care (hospitalization, transport, and accompanying person costs) of the intervention compared to usual diabetes care. Patient, healthcare system, and societal perspectives will be applied for costing. Both cost and health effects will be discounted at 3% per year for within trial cost-effectiveness analysis over 2.5 years and decision modelling analysis over a lifetime horizon. Outcomes will be reported as the incremental cost-effectiveness ratios (ICER) to achieve multiple risk factor control, avoid diabetes-related complications, or QALYs gained against varying levels of willingness to pay threshold values. Sensitivity analyses will be performed to assess uncertainties around ICER estimates by varying costs (95% CIs) across public vs. private settings and using conservative estimates of effect size (95% CIs) for multiple risk factor control. Costs will be reported in US$ 2018.

DISCUSSION

We hypothesize that the additional upfront costs of delivering the intervention will be counterbalanced by improvements in clinical outcomes and patient-reported outcomes, thereby rendering this multi-component QI intervention cost-effective in resource constrained South Asian settings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01212328.

Vitamin-D Toxicity And Other Non-Malignant Causes Of Hypercalcemia: A Retrospective Study At A Tertiary Care Hospital In Pakistan

BACKGROUND

Hypercalcemia is a common clinical problem; primary hyperparathyroidism and malignancy is commonest causes of hypercalcemia. Aetiology of hypercalcemia are changing, causes that were diseases of the past like Vitamin-D toxicity and milk alkali syndrome are observed more often. Vitamin-D deficiency is an important problem and overzealous replacement of Vitamin-D has been observed, suspected to cause toxicity.

METHODS

This was a retrospective review of patients admitted at the Aga Khan University Hospital from January 2008 to December 2013 with hypercalcemia. We reviewed the electronic health records for laboratory and radiological studies, and discharge summaries to establish the cause of hypercalcemia. Patients with solid tumour malignancy were excluded from the analysis. The treatment records and hospital course of patients diagnosed with Vitamin-D toxicity were also reviewed.

RESULTS

Primary hyperparathyroidism was the most common cause of hypercalcemia comprising 41 (28.2 %) patients. Vitamin-D toxicity was present in 25 (17.3%) and probable Vitamin-D toxicity 11 (7.6 %) inpatients. Vitamin-D toxicity and probable Vitamin-D toxicity together comprised 36 (24.8%) cases. Other causes of hypercalcemia included multiple myeloma 18 (12.4%) patients, tuberculosis 6 (4.1%) patients, chronic kidney disease6 (4.1%) cases, sarcoidosis 4 (2.7%) and lymphoma 3 (2.0%) patients. In 29(20%) patients a cause of hypercalcemia could not be determined and were labelled as undiagnosed cases.

CONCLUSIONS

Vitamin-D toxicity was the second commonest cause of hypercalcemia after primary hyperparathyroidism. Knowledge of the prevalent and emerging causes of hypercalcemia is important for prompt diagnosis and treatment..

Unusual presentation of a young man with disseminated tuberculosis and right ventricular mass

We report a 22-year-old man who presented to the emergency department with worsening shortness of breath and chronic fever for 2 months. Physical examination was unremarkable except for raised jugular venous pressure and palpable liver. Echocardiogram showed a large right ventricular mass causing obstruction at tricuspid valve. A subsequent chest CT scan confirmed the presence of a large mass in the right ventricle. There were multiple enlarged lymph nodes and consolidation in the right upper lobe. Diagnosis of disseminated tuberculosis (TB) was made and later confirmed by histopathology of lymph node biopsy along with positive sputum culture for acid-fast bacilli. Remarkable recovery was observed on antituberculous therapy, with complete disappearance of the cardiac mass on echocardiogram, at 1-year follow-up. Although unusual and rare, myocardial involvement as a large mass should be kept in mind while treating patients with disseminated TB.

Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial

BACKGROUND

Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia.

OBJECTIVE

To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes.

DESIGN

Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328).

SETTING

Diabetes clinics in India and Pakistan.

PATIENTS

1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL).

INTERVENTION

Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records.

MEASUREMENTS

Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes).

RESULTS

Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50% [CI, -0.69% to -0.32%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction.

LIMITATION

Findings were confined to urban specialist diabetes clinics.

CONCLUSION

Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute and UnitedHealth Group.

COMPARISON OF VITAMIN D REPLACEMENT STRATEGIES WITH HIGH-DOSE INTRAMUSCULAR OR ORAL CHOLECALCIFEROL: A PROSPECTIVE INTERVENTION STUDY

OBJECTIVE

To ascertain the frequency of correction of vitamin D deficiency (VDD) with single or multiple doses of oral (p.o.) and intramuscular (i.m.) administration of 2 high-dose preparations of vitamin D3 (VD3).

METHODS

This was a prospective intervention study conducted in an ambulatory care setting. One hundred participants with VDD (25-hydroxy vitamin D [25-OHD] <20 ng/mL) were randomized to receive a dose of 600,000 or 200,000 IU of VD3 via a p.o. or i.m. route. The main outcome measure was serum 25-OHD levels at 2, 4, and 6 months after the intervention. The same dose was repeated in participants if 25-OHD remained <30 ng/mL at 2 and 4 months.

RESULTS

At 2 months, VDD was corrected in 93.8% of participants in Group 1 (600,000 IU i.m.); 83.3% in Group 2 (600,000 IU p.o.), 87.5% in Group 3 (200,000 IU i.m.), and 70.6% in Group 4 (200,000 IU p.o.). The mean changes from baseline in vitamin D levels at 2 months were 29.6 ± 13.7, 19.8 ± 12.3, 18.3 ± 10.6, and 13.7 ± 7.8 ng/mL in Groups 1, 2, 3, and 4, respectively. The mean levels remained significantly higher from baseline in all groups at all time points during the 6 months of observation. The mean 25-OHD level achieved in Group 1 was significantly higher than all other groups at 6 months.

CONCLUSION

Two months after the intervention, VDD was corrected in more than 70% of participants with a single dose of either 600,000 or 200,000 IU given p.o. or i.m.

Tumour induced osteomalacia

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic syndrome usually presenting with bone pain, fracture of bones and muscle weakness. It is caused by high serum levels of fibroblast growth factor 23 (FGF- 23), which is a hormone-regulating phosphate, and vitamin D. FGF-23 is secreted by several tumours, especially benign mesenchymal tumours which are very small and difficult to locate. There is a significant delay from onset of symptoms to the diagnosis of this entity dueto occult nature of this disease. We present a case of young male who presented with long history of progressively worsening muscular pain and weakness, rendering the patient confined to bed. Our aim of presenting this patient as a case report is to make physicians realise that any patient with unexplained muscular weakness and pain must undergo workup for TIO, including serum phosphate measurement, as this is a rare but potentially curable disease.

Long-standing undiagnosed sheehan syndrome presenting as polymorphic and monomorphic ventricular tachycardia: a case series of 2 patients

OBJECTIVE

To describe 2 cases of Sheehan syndrome presenting with ventricular tachycardia.

METHODS

In this case series, we present 2 cases of Sheehan syndrome presenting with ventricular tachycardia, which is an extremely rare complication of Sheehan syndrome. We review the literature for cases of panhypopituitarism presenting with ventricular tachycardia and also review the pathophysiologic mechanisms underlying development of ventricular tachycardia in these patients.

RESULTS

Two female patients presented with ventricular tachycardia. One patient had monomorphic and the other had polymorphic ventricular tachycardia. On further workup, both patients were found to have panhypopituitarism. Due to past history of postpartum hemorrhage, both patients were suspected of having Sheehan syndrome as the cause of panhypopituitarism. Electrocardiogram revealed prolonged QT interval. Both patients were started on hormone replacement therapy. Both patients responded well initially and were discharged home. One of the patients is alive and healthy at the time of this report. However, the other patient was readmitted with seizures a few days after discharge and unfortunately died of sudden cardiac arrest.

CONCLUSION

Untreated cases of Sheehan syndrome can present with fatal ventricular tachycardia. Hormone replacement in these patients can treat and prevent fatal arrhythmias.

Diabetic ketoacidosis associated with tacrolimus in solid organ transplant recipients

Diabetic ketoacidosis in patients receiving tacrolimus in the post-transplant setting is rare. We describe two such cases in solid-organ transplant recipients. The first patient, a 17-year-old male, presented with severe diabetic ketoacidosis and was managed with intravenous fluids and insulin infusion. He was a known case of Laurence-Moon-Bardet-Biedl syndrome and had received a renal transplant 2 years ago and was receiving tacrolimus since then. Although diabetic ketoacidosis resolved in 24 hours, large doses of subcutaneous insulin (upto 130 units per day) were needed to keep serum glucose within the normal range. Substitution of tacrolimus with cyclosporine obviated the need for insulin or oral hypoglycaemics. The second patient, a 55-year-old woman, presented with a history of polyuria for 3 days. She had received a hepatic transplant 2 years ago and tacrolimus was being used since then. Mild diabetic ketoacidosis was managed with fluid resuscitation and subcutaneous insulin. Her insulin requirement after an uneventful recovery has been 54 - 70 units per day. Clinicians should be cognizant of the possibility of hyperglycaemic crisis presenting as sudden onset of diabetic ketocidosis in patients receiving tacrolimus. Use of an alternative calcineurin inhibitor may provide a safer solution to minimize future morbidity in such patients.