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Problem considered: Type 2 diabetes mellitus (T2DM) is a global pandemic with increasing prevalence worldwide. Hearsay, or reported speech, is an important contributor to diabetes care related behavior and may influence the outcomes of diabetes treatment. An emerging concept in preventive medicine is Quinary prevention which aims at preventing health-related hearsay or misinformation. Methods: A group of international clinical experts comprising endocrinologists, diabetologists, cardiologists and community medicine specialists gathered in India and discussed ways to restrain the menace of de-hearsay in diabetes care. Results: Based on the discussion, the expert panel endorsed the term ‘quinary prevention,’ which is a mode of preventing the spread of false health information. The panel also outlined several means through which the physician community can prevent the spread of misinformation. Conclusions: Considering the increasing use of technology by the general population, treating health care professionals should keep updating with the newer research evidences in their fields and disseminate authentic knowledge on diabetes care on social media, print media as well as other mass media, thereby diabetes promoting self-management, as well as public health.

Aim: The Prevalence of Atherosclerotic Cardiovascular Disease in Patients with Type 2 Diabetes across the Middle East and Africa (PACT-MEA) study compared cardiovascular disease (CVD) risk and 2021 ESC guidelines adherence between UAE and broader MEA region participants for enhanced type 2 diabetes mellitus (T2D) and atherosclerotic cardiovascular disease (ASCVD)., Methods: A survey of 385 physicians explored clinical decision-making factors. Chart reviews of 3726 participants classified ASCVD risk as per 2021 ESC guidelines and compared T2D target achievement in primary and secondary care centers., Results: The survey highlighted factors influencing T2D management decisions, with most adhering to international guidelines. Among 542 UAE participants, 62.7 % were at high and 37.1 % at very high risk for ASCVD. Target HbA 1c was achieved 45 % UAE vs. 37 % in regionally, BP by 41 % vs. 30 %, LDL by 36 % vs. 30 %, BMI <25 kg/m 2 by 20 % vs. 15 %, SGLT2is use by 63 % vs. 37 % and GLP-1RAs use by 22 % vs. 13 %, respectively. No participants met all ESC-recommended targets for T2D., Conclusion: Physicians followed international guidelines, considering patient history, drug efficacy, and HbA1c levels for diabetes and ASCVD risks. In UAE, <50 % of at-risk individuals with T2D met ESC targets. Cardioprotective medication use was higher in UAE., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2025. Published by Elsevier B.V.)

Introduction: Oral semaglutide, a glucagon-like peptide 1 receptor agonist, requires administration on an empty stomach with up to 120 mL of water, followed by no intake of food, beverages, or other oral medications for at least 30 min to ensure optimal absorption. These instructions can be challenging to adhere to during Ramadan when patients fast for extended periods. The O-SEMA-FAST study assessed the impact of fasting on adherence to oral semaglutide dosing instructions and its subsequent effects on glycaemic control and body weight., Methods: O-SEMA-FAST was a non-interventional, prospective study conducted in 2023 in people with type 2 diabetes mellitus (T2DM) who fasted during Ramadan and were on oral semaglutide treatment in the United Arab Emirates, Saudi Arabia, and Kuwait. Patients were followed for 20 weeks. Glycated haemoglobin (HbA1c) and body weight were measured at baseline and at the end of the study (EOS); changes were analysed by mixed models for repeated measures., Results: Among the 257 patients included in the final analysis, there was a significant reduction in HbA1c (- 0.2%-points, p = 0.01) and a notable decrease in body weight (- 2.6 kg, p < 0.0001) from baseline to EOS. Of the 215 patients who recorded administration details in their diaries, 68.4% (n = 147) adhered to dosing instructions for ≥ 80% of diary days. Baseline mean HbA1c was 6.7% in adherent patients and 7.0% in non-adherent patients. At EOS, the change in HbA1c was - 0.3%-points (95% confidence interval, CI - 0.4, - 0.2; p < 0.0001) for adherent patients and - 0.1%-points (95% CI - 0.4, 0.1; p = 0.3) for non-adherent patients. The change in body weight was - 3.2 kg (95% CI - 4.0, - 2.4; p < 0.0001) for adherent patients and - 1.6 kg (95% CI - 2.5, - 0.8; p = 0.0001) for non-adherent patients. An increase in self-reported hypoglycaemic events (HEs) was observed, but no severe events were reported. Gastrointestinal disorders were the most common adverse effects. Among patients with available data on self-reported HEs (n = 216), 67 (31.0%) experienced HEs. The mean age, HbA1c levels and T2DM duration of patients with vs without HEs were 51.0 vs 53.3 years, 6.99 vs 6.66% and 9.2 vs 7.9 years. A greater proportion of patients experiencing HEs were treated with oral antidiabetic drugs like biguanides (90.6% vs 86.7%), sodium glucose cotransporter 2 inhibitors (85.9% vs 80.7%), sulfonylureas (32.8% vs 25.9%) and dipeptidyl peptidase 4 inhibitors (20.3% vs 11.1%)., Conclusion: The O-SEMA-FAST study demonstrated that most participants adhered to oral semaglutide instructions and experienced significant reductions in HbA1c and body weight. Overall, baseline characteristics were similar regardless of HEs; however, patients reporting HEs were younger, had higher HbA1c levels, longer T2DM duration and were under polypharmacy. Oral semaglutide is a suitable choice for individuals who fast during Ramadan, effectively controlling glycaemic levels and managing body weight while maintaining a favourable safety profile., Trial Registration: NCT05716724., Competing Interests: Declarations. Conflict of Interest: Mohamed Hassanein has received honorarium from Novo Nordisk, Eli Lilly, Sanofi, Novartis and MSD; has received Lecture/Other Fees from Novo Nordisk, Eli Lilly, Sanofi, Novartis and MSD and he is a principal investigator. Fatheya Al Awadi has nothing to disclose. Ibrahim AlKadim has received honorarium from Novo Nordisk and Eli Lilly; has received Lecture/Other Fees from Novo Nordisk, AstraZeneca, Sanofi, Eli Lilly, Boehringer Ingelheim, SPIMACO and he has shares in Novo Nordisk and Eli Lilly. Hazem Aly is an employee of Novo Nordisk. Dalila Bajawi has received honorarium from Novo Nordisk, AstraZeneca, Boehringer Ingelheim, Sanofi, Eli Lilly, Novartis, Bayer, Merck, Organon, Hikma, Tabuk and participated in trials sponsored by Novo Nordisk and Sanofi. Tarhan Cinar is an employee of Novo Nordisk. Dinesh Dhanwal has received honorarium from Novo Nordisk, Lilly, MSD, Boehringer Ingelheim, Hikma, AstraZeneca and participated in trials sponsored by Novo Nordisk and Lilly, Abdul Jabbar has received honorarium from Novo Nordisk, Lilly, Merck, Boehringer Ingelheim, Abbott, Novartis and participated in trials sponsored by Novo Nordisk, Said Khader has received honorarium from Novo Nordisk, BI, Sanofi, Lilly, AstraZeneca and participated in trials sponsored by Novo Nordisk and Sanofi. Khaled Khudadah has received honorarium from Novo Nordisk. Talal Muzaffar has nothing to disclose. Mary Ngome is an employee of Novo Nordisk. Jalal Nafach has received honorarium Novo Nordisk, Sanofi, MSD, Boehringer Ingelheim, Pfizer, AstraZeneca, P&G and participated in trials sponsored by Novo Nordisk, Sanofi, AstraZeneca, received non-financial support from Novo Nordisk, Amna Shaghouli has received honorarium from Novo Nordisk, Eli Lilly and Boehringer Ingelheim. Ethical Approval: The study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from local institutional review boards, ethics committees and regulatory authorities (if applicable). All patients provided informed written consent to participate in the study. The institutional review boards included Jeddah Central Ministry of Health Institutional Review Board, Al Mouwasat Institutional Review Board, Sulaiman Al Habib central Institutional Review Board, King Fahad Medical City (KFMC), Almoosa hopital Institutional Review Board, Gulf Medical University Institutional Review Board, National Medical Commission (NMC) local Institutional Review Board. Regulatory bodies included Ministry of Health (MOH), Saudi Food and Drug Authority (SFDA), Dubai Health Authority (DHA), Ministry of Health and Prevention of the United Arab Emirates (MOHAP). The study is registered with ClinicalTrials.gov (NCT05716724)., (© 2025. The Author(s).)

Background: The outbreak of coronavirus disease (COVID-19) has posed a major threat to people's lives across the globe. It has drastically changed the way we perceive this world. A paradigm shift was observed globally as the world's emphasis shifted to testing, diagnosis, treatment, and developing a coronavirus cure. Clinical trials were also not untouched by this. The coronavirus pandemic has abhorrently affected the day-to-day clinical trial activities at sites., Methods: The status of various ongoing clinical trials was assessed through a literature search, which also includes clinical trial portals. Our evaluations were based on these observations., Results: Multiple challenges were present in clinical trials as recruitment, retention, the safety of trial subjects, protocol compliance, and this made the world to re-think to incorporate newer strategies and to cope with this untoward situation., Conclusion: Digitalization of clinical trials as virtual management of adverse events, remote monitoring visits, and web-based consulting with trial subjects are potential directions that can be applied to better manage clinical trials worldwide., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background and Aims: Patients on long term anti-epileptic drug therapy are prone for Vitamin D deficiency for a myriad of reasons. The aim of this research was to study the effect of high dose vitamin D supplementation on vitamin D nutrition status of children newly started on anti-epileptic drug therapy., Materials: This randomized controlled trial was conducted in a tertiary care Children's Hospital at New Delhi from November 2011 to March 2013. Eighty three children in the age group 5-10 years newly started on anti-epileptic drugs (AED) were randomized into two groups; group A - the intervention group, to whom 60,000 IU vitamin D3 was given orally/month under direct supervision along with AED for a period of 6 months, and group B- the control group, to whom AED without vitamin D3 was given. Serum 25(OH)D, ionized calcium (iCa), total calcium (tCa), inorganic phosphate (iP), alkaline phosphatase (ALP) and parathyroid hormone (PTH) levels were assayed at baseline and at the end of 6 months and were compared within and between the two groups., Results: The mean 25(OH)D in Group A was maintained at 6 months follow up [ 26 ng/ml, 95% CI 20-34 ng/ml] compared to baseline [25 ng/ml, 95% CI -19 to 33 ng/ml] [ p = 0.83]. In group B, there was a significant decrease in 25(OH)D levels at 6 months [13 ng/ml (95% CI 9 ng/ml-17 ng/ml)] compared to baseline [18 ng/ml (95% CI 13-24 ng/ml)] [p = 0.01]. At 6 months, mean serum 25(OH)D was significantly higher in group A as compared to group B (p = 0.005)., Conclusion: To conclude, oral administration of 60,000 IU vitamin D3/month is sufficient to maintain serum 25(OH)D level and prevent development of vitamin D deficiency in children newly started on AED over a period of 6 months. Non supplementation leads to the lowering of serum 25(OH)D in these children., Trial Registration Number: CTRI/2017/08/009234., (Copyright © 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Objectives: This analytic retrospective case-control study was designed to analyze risk factors and the epidemiological profile of hip fractures among the Indian population with special importance to the mechanism of injuries., Methods: Patients of hip fractures (n = 41) and age- and sex-matched healthy volunteers (n = 41) were interviewed by a questionnaire regarding the occurrence of the fracture, past history of diseases and long-term medication usage, past and physical activity, supplements, smoking, and alcohol intake. The data were tabulated using descriptive statistics and logistic regression was used to determine significant risk factors., Results: Age group 60-69 was found to be most affected by hip fractures, though an early onset of fractures was noted in males. Falls due to slipping indoors from standing position was found very commonly. However, an increasing trend of falls was noted from lying down position in the older age groups which was more common during the morning and night hours. Logistic regression analysis for the detection of risk factors was applied to the various variables in the questionnaire. Active status in the past was inversely related (odds ratio [OR], 0.33; P < 0.05) to fracture risk while alternative medication usage in the past 1 year (OR, 4.086; P < 0.05) and significant alcohol consumption were directly associated with fracture risk (OR, 5.484; P < 0.05). A potential inverse relation of use of calcium supplements in the past 3 months and fracture risk (OR, 0.872) was seen, although this was not significant. A potential positive relation of smoking with hip fractures was also seen, but not found significant (OR, 2.204)., Conclusions: Hip fractures in the elderly population are on a rising trend especially in the Indian subcontinent due to a number of factors both hereditary and acquired. Simple measures like routine usage of bedside railing, wall-side railings at an appropriate height, high friction tiles inside rooms and washrooms, and adequate lighting indoors can play a significant role in reducing falls and hip fractures among the elderly.

Background: To evaluate if hormonal profile of children with isolated hypospadias (IH) associates better with comprehensive local anatomical factor score (LAFS) than with clinically adjudged urethral meatus location or severity of chordee/k.j., Material and Methods: Ninety-nine children with IH were enrolled, as per inclusion criteria. Meatal location was recorded at first clinical examination in OPD; while LAFS was computed per-operatively using indigenously devised scale, except for neonates. Hypospadiacs were first classified into three standard meatal based groups and subsequently into LAFS based two groups (≤19, >19). For all participants, pre HCG and post HCG (96 hour post- injection) estimation of serum gonadotropins, DHEA-S, estrogen (E), progesterone (P), testosterone (T) and Dihydrotestosterone (DHT) was done. Statistical tests were applied to assess significance of hormonal levels with respect to meatal location, chordee and LAFS., Results: Only FSH levels differed significantly among meatal based groups; while among LAFS groups, multiple hormonal differences were noted; with poor LAFS associated significantly with higher FSH, LH and lower E, T/DHT. Children with severe degree of chordee had poorer T output and a significantly lower LAFS as compared to those with moderate/mild chordee., Conclusion: Serotoli cell dysfunction, indirectly indicated by high FSH was found among midpenile hypospadiacs and those with poorer LAFS. Since groups based on LAFS revealed multiple intergroup hormonal differences than what was seen for meatal/chordee based groups; LAFS should be considered a better guide for prognostication and for deciding about hormonal supplementation. Lower androgenic output was particularly noted in children with severe chordee.

Objective: Comparison of efficacy and safety of two different regimens of vitamin D-600 000 IU as a single intramuscular dose, and 60 000IU orally once a week for 10 weeks-in treatment of nutritional rickets., Methods: Children with nutritional rickets (age: 0.5-5 years, n = 61) were randomized to receive either 60 000IU vitamin D orally once a week for 10 weeks or 600 000IU single intramuscular injection. Serum calcium, phosphate, alkaline phosphatase, urinary calcium/creatinine ratio, serum 25 hydroxy vitamin D and radiological score were compared at 12-week follow-up., Results: No difference was found in efficacy of the two regimens on comparing biochemical and radiological parameters. Serum 25 hydroxy vitamin D >100 ng/ml was found in two children in the oral group and one child in the intramuscular group. No child developed hypercalcemia or hypercalciuria after starting treatment., Conclusion: Staggered oral and one-time intramuscular administrations of 600 000IU vitamin D are equally effective and safe in treatment of nutritional rickets., (© The Author [2014]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

An 18-year-old girl presented to the emergency department with a history of noisy breathing and breathlessness progressively increasing for few days. The patient had stridor and tachypnoea. She was tall with a long thin face, wrist sign and high-arched palate suggestive of marfanoid features. X-ray of the neck revealed critical tracheal narrowing. Emergency tracheostomy was performed as a lifesaving procedure. Non-contrast CT neck revealed extratracheal compression by a mass surrounding it. Contrast-enhanced CT scan of the neck revealed heterogeneous mass arising from the right lobe of the thyroid and tracheal deviation with narrowing. Fine-needle aspiration cytology of the mass revealed medullary carcinoma of the thyroid, positive for calcitonin. Calcitonin levels were raised. Apart from the marfanoid features she had localised swellings over the lips, lower eyelid and the lateral aspects of the tongue, clinically suggestive of neuromas. A clinical diagnosis of multiple endocrine neoplasia type 2B syndrome was made. The patient underwent total thyroidectomy with central lymphnode dissection. This case highlights an unusual presentation of a rare disease.

Unlabelled: A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery., Learning Points: Hypothyroidism should be considered in the differential diagnosis of adult females presenting with multicystic ovarian tumours.Adequate thyroid hormone replacement therapy can prevent these patients from undergoing unnecessary and catastrophic ovarian resection.Surgical excision should be considered only when adequate thyroid replacement therapy fails to resolve ovarian enlargement.In younger women with ovarian cysts, it is also desirable to avoid unnecessary surgery so as to not compromise fertility in the future.

Unlabelled: Low serum vitamin D and increased parathormone levels were found to be associated with depression and stress in a wintering expedition of 20 healthy male subjects over a period of 1 year in Antarctica. The continuous daylight during summer and the dark polar winter affect endogenous vitamin D production. Long-term effects on bone health need to be studied further., Purpose: Vitamin D plays a significant role in calcium and bone mineral metabolism and also affects cardiovascular, psychological, and cognitive functions. The ultraviolet B radiation component of sunlight, which shows marked seasonal variation in Antarctica, influences the synthesis of vitamin D. Depression and mood disorders are associated with this extreme photoperiod. In this study, we attempted to gauge the alteration of vitamin D homeostasis in Antarctica and its effect on bone mineral metabolism and mood over a period of 1 year., Materials and Methods: Twenty male subjects who wintered over at India's Antarctic base Maitri (70°45'57″ S, 11°44'09″ E) from November 2010 to December 2011 were studied. Fasting serum samples were collected at baseline, 6 months, and 12 months for serum 25-hydroxyvitamin D, intact parathyroid hormone (PTH), total alkaline phosphatase (ALP), calcium, and phosphate. Beck Depression Inventory (BDI), Positive and Negative Affect Scale (PANAS X), and Perceived Stress Scale were used to measure depression, affect, and stress., Results: Mild vitamin D deficiency was present in two (10 %) subjects on arrival, which increased to seven (35 %) subjects during the polar winter at 6 months. The mean score on the BDI-II screen for depression was significantly higher during midwinter (4.8 ± 3.9) when compared with the baseline value (2.9 ± 2.1). Only 2/20 (10 %) of subjects met the criteria for minor depression. Higher PTH levels at 6 months correlated with a higher PANAS X score (p = 0.021). The mean values of calcium, inorganic phosphorus, and ALP were comparable during the course of the expedition., Conclusion: Low light exposure during the dark polar winter, lower vitamin D, and increased intact PTH levels were found to be associated with depression during 1 year of Antarctic residence. The low dietary intake and decreased solar radiation exposure during the polar winter reduce serum vitamin D levels in otherwise healthy individuals, which suggests that supplementation may be necessary.

Background. Altered circadian cortisol and melatonin rhythms in healthy subjects exposed to an extreme polar photoperiod results in changes in mood and sleep, which can influence cognitive performance. Materials and Methods. We assessed the circadian rhythm of 20 subjects who wintered over at Maitri (70°S, 11°E), India's permanent Antarctic station, from November 2010 to December 2011. Serum cortisol and melatonin levels were measured by radioimmunoassay at 8 am, 3 pm, 8 pm, and 2 am in a single day, once each during the polar summer and winter photoperiods. Conventional psychological tests, Depression, Anxiety, and Stress Scale (DASS-42), Epworth Sleepiness Scale (ESS), and a computerized neurocognitive test battery were used to measure mood, sleep, and cognitive performance. Results. The mean scores for DASS42 were higher during midwinter suggesting the presence of "overwintering." Mean diurnal cortisol levels during summer and winter were comparable, but the levels of melatonin were markedly higher during winter. Higher 8 am melatonin levels were associated with better sleep quality, lower depression scores, and better performance in tasks like attention, visual memory, and arithmetic. Conclusion. Timing of artificial light exposure and usage of melatonin supplements in improving sleep and cognitive performance in expedition teams are of future research interest.

Unlabelled: In this large, population-based, prospective, mother-offspring cohort study, maternal long chain polyunsaturated fatty acid (LCPUFA) status during pregnancy was found to be positively associated with bone mass in the offspring at age 4 years. The findings suggest that variation in intrauterine exposure to n-3 and n-6 LCPUFAs may have potential consequences for skeletal development., Introduction: Maternal diet in pregnancy has been linked to childhood bone mass, but the mechanisms and nutrients involved are uncertain. Long-chain polyunsaturated fatty acids (LCPUFAs) have been shown to affect bone metabolism, but the relationship between maternal fatty acid status and bone mass in the offspring remains unknown., Methods: We evaluated the association between maternal LCPUFA status in late pregnancy (34 weeks gestation) and bone density in their children at age 4 years within 727 mother-child pairs taking part in the Southampton Women's Survey., Results: Concentrations of the n-3 LCPUFA component of maternal plasma phosphatidylcholine were positively associated with a number of bone mineral measures at the age of 4 years; these associations persisted after adjustment for maternal body build, walking speed and infant feeding. Relationships were most evident for eicosapentaenoic acid (r = 0.09, p = 0.02 for whole body areal bone mineral density [aBMD] and r = 0.1, p = 0.008 for lumbar spine aBMD) and for docosapentaenoic acid (r = 0.09, p = 0.02 for whole body aBMD and r = 0.12, p = 0.002 for lumbar spine aBMD)., Conclusions: These findings suggest that variation in early exposure to n-3 and n-6 LCPUFA may have potential consequences for bone development and that the effects appear to persist into early childhood.

Aim: The objective of this study is to compare the hormonal profile of children with isolated hypospadias to controls and hypospadiacs with associated anomalies., Study Design: Prospective observation at a tertiary referral hospital., Study Subjects: One hundred consecutive children (0-12 years) with isolated hypospadias (H), 23 with hypospadias and associated anomalies (HO)., Controls: One hundred children (0-12 years) without any genitourinary/endocrine abnormalities (C)., Procedure: Prehuman chorionic gonadotropin (HCG) and post-HCG fasting blood samples were drawn for estimation of serum gonadotropins, dehydroepiandrosterone sulfate (DHEA-S), estrogen (E), progesterone (P), and testosterone (T) and dihydrotestosterone (DHT)., Statistical Analysis: Differences in hormonal levels between controls and subjects were computed with p < or = 0.05 as significant., Results: Compared with controls, "H" had significantly higher follicular stimulating hormone (FSH) (1.37 vs. 1.29 mIU/mL p=0.01), lower estrogen (8.08 vs. 13.78 pg/mL, p=0.00), and lower DHEA-S (27.34 vs. 40.24 microg/dL, p=0.03) levels; HO had higher FSH, lower basal T (0.13 vs. 0.46 ng/mL, p=0.01), and lower peak testosterone (1.53 vs. 2.32 ng/mL, p=0.01). "HO" had lower androgens (basal T, 0.13 vs. 0.29 ng/mL, p=0.03; peak T, 1.53 vs. 2.36 ng/mL, p=0.01), and higher estrogen (12.56 vs. 8.08 pg/mL, p=0.001) and progesterone (0.46 vs. 0.31 ng/mL, p=0.04) levels in comparison with H., Conclusion: Consistently lower output of androgens among HO explains the association of other anomalies (generally undescended testes) in them. High FSH among hypospadiacs hints at the possibility of Sertoli cell dysfunction and may have long-lasting sequelae for reproductive functions during adulthood. However, Leydig cell functions are affected more among HO.

Streptococcal toxic shock syndrome (STSS) which is the most severe form of invasive infection caused by group A streptococci has made a global resurgence. To establish the presence of STSS, hypotension and multiorgan failure must accompany evidence of Streptococcal pyogenes infection. We report a case of STSS in a 61 year old diabetic man. The patient presented with septicaemia and septic arthritis of the right knee joint. Group A streptococci were cultured from both blood and pus aspirate from knee joint. The patient had signs of STSS. Early radical drainage debridement plus appropriate antibiotic therapy altered the usual devastating outcome. A wider recognition of the diverse clinical manifestations of group A streptococci is emphasized for early diagnosis, better treatment and possibly improved outcome.

Ectopic thyroid glands generally occur in the midline as a result of abnormal median migration, and their presence lateral to the midline is rare. A 12-year-old boy had a swelling in the left submandibular region that imaging techniques showed to be an ectopic thyroid gland, although no thyroid tissue was seen in the normal location. Only eight cases of lateral aberrant thyroid tissue have been reported. The importance of being aware of the possibility of ectopic thyroid tissue as a submandibular region swelling has an important bearing on disease management. A pertinent review of the literature and its management is included.

Accelerated coronary and peripheral vascular atherosclerosis is one of the most common and chronic complications of diabetes mellitus. A relatively recently analysed aspect of coronary artery disease in this condition is its silent or asymptomatic nature. We studied silent/asymptomatic myocardial ischaemia in unselected consecutive middle aged asymptomatic diabetics and controls by 24-hour ambulatory electrocardiographic monitoring, treadmill test and coronary angiography. Also, a relationship was sought between silent myocardial ischaemia and autonomic dysfunction. Thirty asymptomatic diabetics between the ages 35-60 without any documented evidence of coronary artery disease and as many controls (matched for age, sex, smoking habits, blood pressure, serum cholesterol and body mass index) were studied. All the diabetics and controls were subjected to treadmill test and 24-hour ambulatory electrocardiographic monitoring. Coronary angiography was done in those who were positive in treadmill test or 24-hour ambulatory electrocardiographic monitoring. Also five simple bedside tests for autonomic dysfuncton i.e. heart rate response to valsalva, deep breathing and orthostatic variation and blood pressure response to orthostatic variation and sustained handgrip were done in all the subjects. Those with two or more abnormal tests were diagnosed as having autonomic dysfunction. ST segment depression indicating silent myocardial ischaemia was seen in 14 (46.7%) out of 30 diabetics and in 3 (10.0%) out of 30 controls on both Holter and treadmill test (p=0.002). Also, diabetics had higher heart rate and greater number of supraventricular and ventricular ectopics than controls. Coronary angiography done in patients with silent ischaemia revealed higher prevalence of multivessel involvement and diffuse disease in diabetics as compared to controls. Half the diabetics (50%) and none of the control had autonomic dysfunction. Autonomic dysfunction was present in 85.7 percent of diabetics with silent ischaemia compared to 18.7 percent diabetics without silent ischaemia (p=0.001).