admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

With the deteriorating situation during the COVID-19 pandemic, healthcare workers and medical students posted in wards are also supposed to be at risk of getting infected. This study aimed to evaluate knowledge, risk perception, and preventive behaviors related to the COVID-19 pandemic among undergraduate medical students in Egypt. This is a cross-sectional observational study using an anonymous online questionnaire. The survey was conducted through a link shared on social networking sites. Data were collected from 19 June 2020 to 26 June 2020. The medical students of Suez Canal University fulfilled the inclusion criteria and agreed to participate in the study were included by using convenience and snowball sampling technique (283 students). The total related knowledge score was 80.9%. The majority (83%) feel that coronavirus infection is a life-threatening illness. About 86.9% of the students perceived a COVID-19-infected person as a serious threat to society. However, three-quarters of the students (76.3%) perceived risk of infection with COVID-19 during ward rotations. About 92% of the students are practicing preventive behaviors. Female senior students have higher percentages in regard to related knowledge and practicing preventive behaviors. Students who received education about Covid-19 and students perceived higher risk of infection were more adherent to preventive measures. There is a moderate correlation between related knowledge and practicing preventive behaviors. Medical students have good knowledge, practice preventive behaviors, and perceive risk of being infected. The direction to raise knowledge and awareness will enhance practicing preventive behaviors to control the disease.

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Knowledge, Risk Perception, and Preventive Behaviors Related to COVID-19 Pandemic Among Undergraduate Medical Students in Egypt.

The prevalence of obesity continues to rise worldwide despite evidence-based public health recommendations. The promise to adopt a healthy lifestyle is increasingly important for tackling this global epidemic. Calorie restriction or regular exercise or a combination of the two is accepted as an effective strategy in preventing or treating obesity. Furthermore, the benefits conferred by regular exercise to overcome obesity are attributed not only to reduced adiposity or reduced levels of circulating lipids but also to the proteins, peptides, enzymes, and metabolites that are released from contracting skeletal muscle or other organs. The secretion of these molecules called cytokines in response to exercise induces browning of white adipose tissue by increasing the expression of brown adipocyte-specific genes within the white adipose tissue, suggesting that exercise-induced cytokines may play a significant role in preventing obesity. In this review, we present research-based evidence supporting the effects of exercise and various diet interventions on preventing obesity and adipose tissue health. We also discuss the interplay between adipose tissue and the cytokines secreted from skeletal muscle and other organs that are known to affect adipose tissue and metabolism.

The Role of Exercise, Diet, and Cytokines in Preventing Obesity and Improving Adipose Tissue

Nowadays, diabetes and obesity are two main health-threatening metabolic disorders in the world, which increase the risk for many chronic diseases. Apelin, a peptide hormone, exerts its effect by binding with angiotensin II protein J receptor (APJ) and is considered to be linked with diabetes and obesity. Apelin and its receptor are widely present in the body and are involved in many physiological processes, such as glucose and lipid metabolism, homeostasis, endocrine response to stress, and angiogenesis. In this review, we summarize the literatures on the role of the Apelin–APJ system in diabetes and obesity for a better understanding of the mechanism and function of apelin and its receptor in the pathophysiology of diseases that may contribute to the development of new therapies.

The Role of Apelin–APJ System in Diabetes and Obesity

Oncological emergencies are defined as any acute possible morbid or life-threatening events in patients with cancer either because of the malignancy or because of their treatment. These events may occur at any time during malignancy, from symptoms present to end-stage disease. The aim of this study is the review of urgent conditions results from cancer or cancer treatment side effects that need to be addressed immediately. In this study, a comprehensive and in-depth narrative review was carried out by searching the databases of PubMed, Scopus, Science Direct, Google Scholar with the keywords of "cancer, emergency, metabolic emergency, neutropenic fever" along with the words, "tumor lysis syndrome, chemotherapeutic emergency, diagnosis, treatment " in last two decades. Patients suffering from cancer mostly face the challenges that we are classified in different categories, including metabolic, hematologic, cardiovascular, neurologic, respiratory, infectious, and chemotherapeutic emergencies. These patients mostly complain of headaches, nausea, pain, and fever. In conclusion, knowledge of oncology emergencies and palliative care as part of a team approach is critical for treating cancer patients. In this light, it is pivotal for physicians to focus on the early detection of oncological emergencies. Moreover, training programs for cancer patients help them to timely recognize and report the oncologic emergency symptoms, leading to avoid deleterious consequences and unnecessary healthcare costs as well as improve the quality of life in these patients.

Oncological Emergencies from Pathophysiology and Diagnosis to Treatment: A Narrative Review.

Introduction: The aim of this study was to assess the knowledge, attitude, and behavior of medical students about the COVID-19 and the effect of the outbreak on the students' anxiety levels. Methods: The cross-sectional study was carried out between 07-14 April, with the online questionnaire forms applied to the medical students. A questionnaire forms were sent to one of every two students in the faculty using the systematic sampling method. A total of 530 volunteers were included in the study. The data was collected through a self-administered questionnaire of the socio-demographic characteristics, opinions about the epidemic, knowledge, and attitude of medical students regarding COVID-19. Anxiety levels of the participants were measured with the State-Trait anxiety inventory. Results: A total of 530 medical students had a mean score of knowledge and attitude of 7.83±1.27 and 45.18±5.12, respectively. Participants demonstrated good knowledge and a positive attitude towards COVID-19. Clinical period students had a higher level of knowledge (p<0.001) and positive attitude (p=0.025) compared to preclinical students. While the knowledge score was higher in men (p = 0.033), the attitude score was higher in women (p <0.001). There was a negative correlation between attitude scores and state (p=0.003) and trait anxiety scores (p<0.001). Conclusion: Medical students had sufficient knowledge and attitude towards COVID-19. Anxiety caused by the outbreak may have negative effects on the positive attitudes of the participants.

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Knowledge, attitude and anxiety of medical students about the current COVID-19 outbreak in Turkey

Objective: This study aims to investigate the relationship of monocyte to high-density lipoprotein cholesterol ratio (MHR) with diabetes mellitus (DM) and diabetic nephropathy.
Methods: This study included 262 Type-2 diabetes mellitus patients, of which 60 had diabetic nephropathy and 202 did not have diabetic nephropathy who presented to the internal diseases polyclinic at Firat University Medical Faculty Hospital between May 2018 and October 2018 and 50 healthy control subjects. A retrospective scan of patient files was conducted and information relevant to nephropathy such as hemoglobin, glycated hemoglobin levels (HbA1c), hematocrit count (HCT), monocyte count, LDL, HDL, triglyceride levels, and microvascular complications were acquired.
Results: We determined MHR values as 11.9±5.5 and 8.4±2.9 respectively for the diabetic and healthy groups. There was a statistically significant difference between the two groups in terms of MHR, with a positive correlation between diabetes and MHR (< 0.001; r: 0.241). Moreover, glucose, HDL, and triglyceride levels were different between the two groups with statistical significance (respectively, p< 0.001; p< 0.001; p< 0.001). Our study found higher MHR levels for patients with diabetic nephropathy compared to those without diabetic nephropathy (respectively, 17.1±7.9 and 10.3±3.3) and determined statistical significance and a negative correlation (p< 0.001; r: -0.512).
Conclusion: Our results suggest that an elevated MHR can be a biomarker for diabetic nephropathy, allowing the detection of diabetic nephropathy with simple and inexpensive laboratory tests.
doi: https://doi.org/10.12669/pjms.35.4.534
How to cite this:Onalan E. The relationship between monocyte to high-density lipoprotein cholesterol ratio and diabetic nephropathy. Pak J Med Sci. 2019;35(4):1081-1086. doi: https://doi.org/10.12669/pjms.35.4.534
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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The relationship between monocyte to high-density lipoprotein cholesterol ratio and diabetic nephropathy.

Objective: To examine potential associations between neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, mean platelet volume (MPV), HbA1c and microvascular complications in diabetic patients from a cost-effectiveness perspective.
Methods: One hundred patients with type 2 diabetes attending our outpatient unit between May 2018 and October 2018 were included, and 100 healthy individuals served as the control group. A retrospective file search was performed to collect information on hemoglobin, mean platelet volume (MPV), glycosylated haemoglobin (HbA1c), hematocrit (Hct), neutrophil and lymphocyte count, neutrophil/lymphocyte ratio (NLR), platelets (Plt), platelet/lymphocyte ratio (PLR), and microvascular complications (neuropathy, retinopathy, nephropathy).
Results: Demographic and laboratory data were retrospectively controlled between diabetes (n=100) and healthy control (n=100) groups. The mean age in diabetic patients and healthy controls was 56.34 and 36.68 years, respectively. The mean NLR in diabetics and healthy controls was 2.48 and 2.11, the difference in NLR being significant (p=0.002). MPV in diabetics and controls was 8.54 and 8.53, respectively, and the difference was not significant (p=0.93). PLR was also similar, i.e. 149.7 and 145.3 in diabetics and healthy controls (p=0.067). With respect to microvascular complications, retinopathy was found to be significantly associated with MPV and NLR (p=0.015, and p=0.051), and nephropathy showed a significant association with NLR (p=0.027) among diabetics. In contrast with the two other microvascular complications, no significant association between neuropathy and NLR could be detected, while PLR and neuropathy was significantly associated (p=0.003).
Conclusion: Microvascular complications may be associated with certain hematologic parameters, as suggested by comparisons both between diabetics and healthy individuals and within the group of diabetic individuals. We believe that hematologic parameters such as hematocrit, MPV, NLR, and PLR, which can be obtained through a simple complete blood count, may be utilized as cost-effective predictors of diabetic microvascular complications. Further prospective studies with larger sample size are required to better delineate these associations.
doi: https://doi.org/10.12669/pjms.35.6.1150
How to cite this:Onalan E, Gozel N, Donder E. Can hematological parameters in type 2 diabetes predict microvascular complication development? Pak J Med Sci. 2019;35(6):1511-1515. doi: https://doi.org/10.12669/pjms.35.6.1150
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Can hematological parameters in type 2 diabetes predict microvascular complication development

AIM Chronic lymphocytic thyroiditis is among the most common causes of hypothyroidism along with HT (Hashimoto's thyroiditis) goitre, which is also named as autoimmune thyroiditis. Our study aims to determine the usefulness of PLR (platelet to lymphocyte ratio) and NLR (neutrophil to lymphocyte ratio), which can be obtained with a hemogram, at the clinical course or the severity of the disease in patients with Hashimoto's thyroiditis. MATERIALS AND METHODS Our study is a retrospective cross-sectional study that included 121 hypothyroid or subclinical hypothyroid Hashimoto's thyroiditis patients and a healthy control group comprised of 100 individuals. Thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), anti-thyroid peroxidase (anti-TPO), complete blood count (CBC), and C-reactive protein (CRP) results were obtained from patient files for both HT patients and the control group, and we computed PLR and NLR for both groups. RESULTS PLR was lower in patients diagnosed with HT compared to the healthy control group, with statistical significance (respectively, 130.8±50.5 versus 145.3±58.5; p<0,05). NLR was higher in patients diagnosed with HT compared to the control group and a statistically significant relationship was determined (respectively, 2.43±0.94 versus 2,11±0,81; p<0,05). In addition to the present findings, we determined that PLR and NLR were correlated with anti-TPO, TSH, and FT4, although without statistical significance. CONCLUSION As values that can be measured with an inexpensive and easily accessible routine hemogram, PLR and NLR can serve as practical and valuable markers at the clinical course or the severity of the disease and other diseases that are autoimmune and progress with chronic inflammation.

Neutrophil and platelet to lymphocyte ratio in patients with hypothyroid Hashimoto's thyroiditis.

Introduction: Meteorin-like (Metrnl), also known as subfatin, is a recently discovered adipokine with a favourable effect on insulin sensitivity Studies have shown lower Metrnl levels in obese patients However, data on its circulating levels in type 2 diabetes mellitus (T2DM) patients are contradictory This study aims to evaluate serum Metrnl levels in T2DM patients and determine the relationship between serum Metrnl levels and insulin resistance in these patients Material and methods: This cross-sectional study was conducted among 150 participants The study was carried out between June 2019 and December 2019 at the internal medicine outpatient clinic of a tertiary university hospital The participants were divided into three groups: group 1 (control group, n = 50), group 2 (newly diagnosed T2DM, n = 50), and group 3 (long-standing diagnosed T2DM, n = 50) An enzyme-linked immunosorbent assay (ELISA) was used to measure the serum levels of Subfatin (Metrnl), and the correlations of Metrnl level with anthropometric parameters, HOMA index, and biochemical measurements were assessed Results: There was no statistically significant difference between the gender (p = 0468) and age (p = 0067) characteristics of the three groups The Metrnl (subfatin) levels of the participants were as follows: control group – 2005 (156–10378); newly diagnosed T2DM group – 262 (125–10378); and long-standing diagnosed T2DM group – 201 (080–1984) pg/mL The Metrnl (subfatin) levels of the participants in the control group were higher than in the participants in the newly diagnosed T2DM and long-standing diagnosed T2DM groups (p < 0001) Subfatin demonstrated a negative correlation with insulin and HOMA-IR in the control group and long-standing diagnosed T2DM group Conclusions: The subfatin level was found to be higher in the healthy control group than in both diabetic patient groups Subfatin level showed negative correlation with both insulin level and HOMA index There was a relationship between subfatin and insulin resistance Low levels of subfatin in the diabetic patient groups may play a role in the pathogenesis of T2DM by increasing insulin resistance

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Erhan Onalan

Papers

Knowledge, attitude and anxiety of medical students about the current COVID-19 outbreak in Turkey

The relationship between monocyte to high-density lipoprotein cholesterol ratio and diabetic nephropathy.

Can hematological parameters in type 2 diabetes predict microvascular complication development

Neutrophil and platelet to lymphocyte ratio in patients with hypothyroid Hashimoto's thyroiditis.

Low serum levels of meteorin-like/subfatin: an indicator of diabetes mellitus and insulin resistance?