SM Ashrafuzzaman's research while affiliated with Ibrahim Cardiac Hospital & Research Institute and other places

Background: In Bangladesh, patients with thyroid disorders are managed in accordance with the recognized guidelines and based on expert experience, as comprehensive national guidelines are currently lacking. The Bangladesh Endocrine Society (BES), as a professional body, has been working to develop guidelines for the last couple of years. Most recently, BES formulated practical recommendations for the management of thyroid disorders during pregnancy, which will be termed the "Guideline on Thyroid Disorders in Pregnancy in Bangladesh 2022," Methods: The BES formed a task force comprising experts in this field to formulate the practical recommendations for the management of thyroid disorders during pregnancy under several sections. The members of this task force comprehensively reviewed the available evidence for the specific conditions. Three well-known databases (Google Scholar, PubMed, and Scopus) were searched to determine the evidence. The task force members were well trained on reviewing the documents and methods of evidence synthesis. Each section of the recommendation was drafted by one member and subsequently reviewed. There was no barrier to the date or type of article published in the aforementioned databases except for articles published other than English. Due to the scarcity of intervention studies, ideas and findings of observational studies, case studies and expert recommendations were considered during the formulation of the guidelines. All members and affiliated persons declared no competing interest, and it was managed and communicated by the President of the BES. Results: The current guidelines for the management of thyroid disease in pregnancy include recommendations about the screening of thyroid function in pregnancy, planning pregnancy in women with thyroid disorders, interpretation of thyroid function tests, management of hypothyroidism and hyperthyroidism in pregnancy, management of thyroid nodules and thyroid emergencies throughout pregnancy, postpartum care, and directions of future research. Conclusions: Our utmost efforts were centered on developing evidence-based recommendations to inform all the levels of clinicians of Bangladesh for the easy understanding and decision-making processes in the management of thyroid disorders in pregnancy and afterward. While we care most to prepare the guideline, all recommendations are the opinion of society and admit the scope of making individualized decisions for the optimal care of patients.

Autonomic neuropathy is a troublesome complication of diabetes mellitus often is not addressed by the physicians. The aim was to see the accuracy of autonomic symptoms in the detection of severe cardiac autonomic neuropathy (CAN). This study was done in BIRDEM in 62 adult patients with type 2 diabetes mellitus and cardiac autonomic neuropathy. Cardiac autonomic neuropathy was detected clinically by heart rate and blood pressure change to maneuvers such as deep breathing, valsalva and standing. Eight symptoms of autonomic neuropathy, namely exercise intolerance, dizziness, dysphagia, abdominal bloating, constipa- tion, diarrhea, gustatory sweating and impotence were tested. In this study, impotence was the most common symptom (58%). There was no difference in the frequency of autonomic symptoms between severe and non-severe cardiac autonomic neuropathy. Taking clinical tests as gold standard, gustatory sweating had the highest specificity (96%) and constipation had the highest sensitivity (54.05%) in detection of severe cardiac autonomic neuropathy. Sensitivity increased to 78.37 when a constellation of symptoms were tested. Autonomic symptoms are common in patients with type 2 diabetes and cardiac autonomic neuropathy. Collection of symptoms was associated with a high sensitivity for detection of severe cardiac autonomic neuropathy. BSMMU J 2022; 15(1): 11-15

Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus, which may occurin both type 1 and type 2 diabetic patients. It is characterized by hyperglycaemia [blood glucose levels > 250 mg/dL (13.8 mmol/ L)], metabolic acidosis (pH <7.3 or serum bicarbonate <15 mmol/L) with an increased anion gap and the presence of ketone bodies in blood or urine. A subgroup of patients may present without signs of hyperglycemia, rather present with euglycemia, posing a diagnostic challenge due to the absence of the cardinal findings of the pathophysiology in DKA. Here, we report a case of euglycemic ketoacidosis complicating a 50-year-old Bangladeshi diabetic lady receiving empagliflozin treatment. BIRDEM Med J 2021; 11(3): 243-245

Background The year 2020 witnessed a largely unprecedented pandemic of coronavirus disease (COVID-19), caused by SARS COV-2. Many people with COVID-19 have comorbidities, including diabetes, hypertension and cardiovascular diseases, which are significantly associated with worse outcomes. Moreover, COVID-19 itself is allied with deteriorating hyperglycemia. Therefore, Bangladesh Endocrine Society has formulated some practical recommendations for management of diabetes and other endocrine diseases in patients with COVID-19 for use in both primary and specialist care settings. Objective The objective of the article is to develop a guideline to protect the vulnerable group with utmost preference – the elderly and those with comorbid conditions. Therefore, to ensure the adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities. Considering and Monitoring Issues The risk of a fatal outcome from COVID-19 may be up to 50% higher in patients with diabetes than in non-diabetics. Patients with diabetes and COVID had CFR 7.3–9.2%, compared with 0.9–1.4% in patients without comorbidities. Diabetic ketoacidosis may be one of the causes of mortality in COVID-19. There is wide fluctuation of blood glucose in these patients, probably due to irregular diet, reduced exercise, increased glucocorticoids secretion, and use of glucocorticoids. HbA1c should be <7.0% for the majority of the patients, this target may be relaxed in appropriate clinical settings. More emphasis should be given on day-to-day blood glucose levels. Hypoglycemia (<3.9 mmol/l) must be avoided. Frequent monitoring of blood glucose is needed in critically ill patients. Conclusion The fight against COVID-19 has been proven to be a challenging one. Therefore, all healthcare personnel should make the best use of updated knowledge and skills to ensure adequate protective measures and timely treatment for COVID-19 patients with diabetes, other endocrine diseases or any other comorbidities.

Background: Adrenal diseases are common and their presentations are variable. This study aimed to determine the frequency and presenting features of various adrenal diseases in a tertiary care hospital of Bangladesh. Methods: This retrospective descriptive study was carried out in Endocrinology in-patient department of BIRDEM General Hospital, Dhaka, Bangladesh, from October 2017 to December 2018. During this time, total 745 patients were screened; out of whom 91 had adrenal diseases. Results: Mean age of the study population was 39.6±11.5 years. Among them, 65.9% were male. Most (75.8%) cases had adrenal insufficiency, followed by endogenous Cushing’s syndrome (8.8%), Conn’s syndrome (6.6%), non-functioning adenoma (3.3%), congenital adrenal hyperplasia (CAH) (2.2%), pheochromocytoma (1%), myelolipoma (1%) and adrenal carcinoma (1%). According to functional status, most (75.8%) were hypofunctional. Of the patients with adrenal insufficiency, secondary adrenal insufficiency was the most common (78.3%). Among the secondary adrenal insufficiencies, 75.9% had iatrogenic adrenal insufficiency and 24.1% had pituitary diseases. Regarding the cases of primary adrenal insufficiency, 20% cases were due to adrenal tuberculosis, 6.6% were due to adrenal histoplasmosis and 73.3% were idiopathic. Most of the adrenal insufficiency patients presented with hypotension (66.7%), followed by gastrointestinal symptoms (76.8%), weight loss (55.1%), hyponatraemia (42%), pigmentation (13%) and hypoglycemia (10%). In this study, 9.9% patients had adrenal incidentaloma. Most of them (88.9%) were benign. Causes of Cushing’s syndrome among the study population were, iatrogenic (66.7%), adrenal (16.7%) and pituitary cause (16.7%). In this study, 16.5% patients had endocrine hypertension and the causes were endogenous Cushing’s syndrome (53.3%), Conn’s syndrome (40%) and pheochromocytoma (6.7%). Of the hypertensive patients, 60% had co-existing hypokalemia. Conclusion: Adrenal insufficiency was the most common adrenal disorder followed by endogenous Cushing’s syndrome, Conn’s syndrome, non-functioning adenoma and other adrenal disorders. Presentations of adrenal disorders are variable. Among the cause of adrenal insufficiency iatrogenic adrenal insufficiency was the most common. Birdem Med J 2021; 11(2): 103-107

Background: Since March 2019 the outbreak of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Bangladesh. There is variable presentation of COVID-19. Though SARS-CoV-2 primarily involves respiratory system, as time passing on it is evident that it can affect any other system including gastrointestinal, cardiovascular and neurological system. This study described the characteristics of the patients admitted in Department of Endocrinology, BIRDEM General Hospital with non-COVID illness and later revealed positive for SARS-CoV-2. Methods: This observational study was conducted during the period of 13th April to 14thOctober, 2020.Data of all patients admitted in Department of Endocrinology, BIRDEM General Hospital during this period was retractedretrospectively from hospital electronic medical records with prior permission from institutional head. Though admitted for non-COVID illness, patientshavingsymptoms or supportive lab investigations of COVID- 19 were advised RT-PCR for SARS-CoV-2. All hospital records of these suspected COVID-19 cases wererecoded and analyzed by SPSS version 20. Results:Total patients were 63. Among them 21(33.3%) patients were admitted with uncontrolled diabetes (DM),19(30.2%) had other endocrinopathies(later query revealed history of fever),8(9.5%) had newly detected DM,11(7.5%)had hypoglycemia,6(9.6%) had general weakness. Though all study subjects were advised to do RT-PCR for COVID, 22(34.9%) refused the test either due to symptom denial or due to cost of the test and 24(38.1%) become positive. Conclusion: Non-critically ill COVID-19 patients had variable clinical characteristics. This study shows that uncontrolled diabetes mellitus, newly detected diabetes and hypoglycemia are found in patients with COVID- 19 and may not have typical clinical features. Birdem Med J 2020; 10, COVID Supplement: 29-32

The world is suffering from a pandemic of coronavirus disease-2019 (COVID-19), and people with diabetes mellitus (DM) are more vulnerable to the serious effects of the COVID-19. This interaction is alarming, considering the high transmission rate of COVID-19 and the global prevalence of DM. Considering the importance of the link between COVID-19 and DM, Bangladesh Diabetic Association has formed a panel of national and international experts in the field of public health, diabetes, and endocrinology to provide some evidence-based guidance for the prevention and care of people with DM during the COVID-19 pandemic.

Adrenal sarcomatoid carcinoma (ASC) are very rare and aggressive malignant tumors of adrenal glands containing both epithelial (carcinomatous) and mesenchymal (sarcomatous) components. ASC presents a diagnostic challenge due to its atypical symptoms and histological patterns which influence treatment.At the time of diagnosis, a large percentage of patients are already at the metastatic stage and succumb within a few months. Here, we report a case of functional sarcomatoid carcinoma in right adrenal gland in a 37-year-old female, who presented with new onset hypertension. The patient underwent right sided adrenalectomy and she was alive at the time of writing the current report.To the best of our knowledge, ASC reported in literature to date showed only few patient presented with endocrine hypersecretion and only one patient presented with both hypertension and endocrine dysfunction. So, our case is the rarest among the rare. Birdem Med J 2020; 10(1): 73-75

Benign prostatic hyperplasia (BPH) is one of the most common genitourinary complications in men over 50 years of age and typically presents with lower urinary tract symptoms (LUTS) and may need medical and occasionally surgical interventions. Few of them may only need advice on behavioral modification like less water intake after sunset, avoid tea, coffee after evening, avoid alcohol and less use of diuretics. The symptoms related to BPH or LUTS without any prostatic enlargement are incomplete voiding, frequency, intermittency, urgency, weak stream, straining and nocturia. For most patients with mild to moderate symptoms of BPH [International Prostate Symptom Score (IPSS) <8 or 8-19 respectively] monotherapy with an á-1-adrenergic antagonist remains initial treatment. The choice of specific á-adrenergic antagonist agent is generally based on cost and side effect profile. Other classes of medications include 5á-reductase inhibitors and phosphodiesterase (PDE) 5 inhibitors. In men who have mild to moderate symptoms of BPH and concomitant erectile dysfunction (ED), PDE-5 inhibitors are reasonable alternative. Now a days á-1-adrenoceptor blockers and 5á-reductase inhibitors are often combined to give a synergistic effect. A review of the current literature identified several adverse sexual side effects, including ED, decreased libido, orgasmic disorders and ejaculatory disorders. It is important to know the extent of these side effects, as the clinician and patient will need to decide the cost of improved voiding symptoms. The prime adverse effect is ejaculatory disorders including the absence of ejaculation. Clinical consideration for BPH/LUTS should include the elements of male sexual function, patient's age and the characteristics and comprehensive effects of each group of drugs. Methodological bias in clinical studies, such as the subjective evaluation of the sexual side effect makes it difficult to determine the ideal drug for treatment. Men without ED or irritant symptoms who desire medical therapy but cannot tolerate á-1-adrenergic antagonists and do not have predominately irritant symptoms or concomitant ED, treatment with a 5á-reductase inhibitor is a reasonable. Treatment for 6 to 12 months is generally needed before prostate size is sufficiently reduced to improve symptoms. Symptoms are usually reversible, so drugs may need to be continued for long time or indefinitely under supervision of specialist. Key words: adverse effects, benign prostatic hyperplasia, lower urinary tract symptoms, sexual health. (BIRDEM Med J 2019; 9(1): 240-247)

Aims: The aim was to see the frequency of CAN in type 2 diabetes mellitus patients with peripheral neuropathy, and its association with peripheral nerve conduction abnormalities. Methods: A cross-sectional study at BIRDEM was conducted in 62 patients with type 2 diabetes mellitus having electrophysiologically diagnosed peripheral neuropathy. CAN was detected by four clinical tests - heart rate response to deep breathing and valsalva maneuver, blood pressure response to standing and sustained handgrip. Result: The study showed that all patients had CAN - 14.52% had early, 26.67% had definitive and 59.68% had severe CAN. Patients with severe CAN had significantly reduced nerve conduction velocity and amplitude of peripheral nerves (sural 4.36 ± 12.77 vs 9.65 ± 17.77 m/s, p = 0.009; 2.23 ± 1.89 vs 3.01 ± 2.76 mV, p = 0.001; peroneal 7 ± 4.23 vs 8.53 ± 5.99 mV, p = 0.047; tibial 0.008 ± 0.03 vs 0.026 ± 0.05 mV, p = 0.009) and higher serum triglyceride levels (221.17 ± 120.61 vs 197.76 ± 68.43 mg/dl, p = 0.033). Conclusion: Diabetic patients with peripheral neuropathy have CAN, the severity of which increases with worsening neuropathy.