Central diabetes insipidus (CDI) is an uncommon complication of acute myeloid leukemia (AML). Patients present with polyuria either preceding or at the time of diagnosis of AML. We describe the case of a 36-year-old male who presented with a subacute onset of polyuria, polydipsia, nocturia, and fatigue. After an extensive workup, he was diagnosed with AML/CMML (chronic myelomonocytic leukemia) with a normal karyotype with DNMT3A, CBFB, and PTPN11 mutations. Further workup of the polyuria with a water deprivation test helped confirm the diagnosis of CDI along with MRI findings suggestive of hypophysitis. In this report, we analyze the clinical workup for AML and CDI and report the possibility of extramedullary leukemic infiltration associated with DNMT3A mutation, which has been reported as one of the mechanisms in the existing literature. We also discuss other theories hypothesized to cause CDI in AML patients with abnormal karyotypes. Our patient progressed to AML from CMML-2 after a cycle of decitabine, with confirmed gingival and presumed central nervous system (CNS) involvement. He is in minimal residual disease (MRD)-negative complete remission after induction with a CNS-active acute lymphoblastic leukemia-2 regimen. He also received double umbilical cord blood transplantation, conditioned with cyclophosphamide, fludarabine, thiotepa, and total body irradiation (TBI) of 4 Gy. This was complicated by engraftment syndrome for which he is currently being managed. CDI of the patient was corrected by desmopressin administration.

Introduction: During the COVID-19 pandemic, there is a tremendous amount of literature published regularly. In a country like India, historically, where there is a paternalistic approach to practicing medicine, there is a lot of hindrance to evidence-based medicine (EBM). Doctors have always weighed one's clinical experience superior over any other form of decision-making. This system of practice has made decision-making difficult for the physicians during this pandemic as COVID-19 is a reasonably new disease entity and the physicians lack enough 'prior experience' dealing with such a situation. Our survey tries to address the common barriers to evidence-based medical practices especially during the COVID-19 pandemic in India. We also try to explore the various source of information used by the doctors. Methods: It is a descriptive cross-sectional survey. The questions were provided in multiple-choice question format. An online survey comprising of 10 questions entitled “Hurdles faced by physicians to assimilate evidence-based guidelines on COVID-19” was made using Google Forms (Google Inc, California, US) and circulated through email to medical practitioners in the Ghatkopar (Mumbai, India) Medical Association's register from 17th June 2020 to 1st September 2020. Results: Our survey collected 213 responses, out of which 80.3% (n=171) of doctors were involved in care, counseling, or management of COVID-19 patients. The most opted primary sources for evidence-based information during this pandemic were teachings of/discussions with medical colleagues (71.4%, n=152), followed by online webinars (59.6%, n= 127) and social media (41.8%, n=89). When questioned about the main obstacles faced by them to obtain evidence-based information, the responses were as follows: Overload of medical literature (53.5%, n=114), limited access to quality resources (40.8%, n=87), unfamiliarity with the bio-statistics analysis (39%, n= 83), difficulty in locating relevant medical literature (38%, n=81), unfamiliarity with the research methodology (37.1%, n=79), lack of time (30%, n=64).  Our respondents' perspective concerning EBM attributes: 57.3% (n=122) think evidence-based practice takes their clinical experience into account. 93.4% (n=199) of them have shown an interest in broadening their skills. There was no significant difference between doctors' attitudes with less than 10 years and more than 10 years of experience (chi-square value = 0.857, p = 0.65). Conclusion: Our survey results highlight the balance maintained between evidence-based medicine and experience-based medicine by Indian physicians. They identify the importance of EBM while acknowledging its shortcomings. They realize the significance of developing their repertoire to understand, appraise, and practice EBM. Keywords: EBM, COVID-19

Purpose: Sodium-glucose cotransporter 2 (SGLT 2) inhibitors are a novel class of drugs that have emerged as promising therapeutic agents for Diabetes Mellitus, Heart failure as well as chronic kidney disease. Despite their effectiveness, concerns have been raised about the potential side effects of these drugs. To address these concerns, a pharmaco-vigilance study has been designed to evaluate and compare the adverse events reported in clinical trials with those reported in the real-world settings. The study aims to identify any discrepancies between the reported adverse events and assess the safety profile of SGLT2 inhibitors. Methods: We studied diabetic ketoacidosis (DKA), euglycemic DKA, amputation, urinary tract infection (UTI), mycotic genital infection and hypotension associated with empagliflozin, dapagliflozin, canagliflozin and ertugliflozin in RCTs and pharmacovigilance databases. WHO’s VigiBase, FAERS, EMA’s EudraVigilance and DAEN were thoroughly studied to obtain spontaneously reported real-world adverse events. Results: 12 randomized controlled trials (RCTs) for different SGLT2 inhibitors that enrolled 78,802 patients in total were studied for the adverse effects profiles of each drug. Out of the 12 trials included in the current study, UTI was the most reported adverse event in the SGLT2 group, followed by amputation. Out of all the adverse events that were registered in the spontaneous reporting systems, 69,664 were reported for empagliflozin, 51,172 for dapagliflozin, 59,261 for canagliflozin and 1,315 for ertugliflozin. DKA was the most reported adverse event overall. Proportions of composite adverse events were 25.1% in VigiBase, 28.6% in FAERS, 39.1% with EudraVigilance and 55.1% with DAEN. Most of the adverse events were reported by the health care provider. Conclusion: Our study provides comparison of the real world reported adverse events to adverse events reported in the clinical trials studying the efficacy of SGLT 2 inhibitors.

Cocaine-associated coronary artery disease and ST-segment elevation myocardial infarction (STEMI) have been well described in the literature. However, very few cases of cocaine-induced multivessel coronary artery disease have been reported. We report a very rare case of cocaine-associated triple vessel coronary artery disease in a 41-year-old male patient. The patient underwent urgent catheterization that revealed occlusion of his proximal left anterior descending artery (LAD), mid-circumflex artery, and right coronary artery with angioplasty and stent placement. His hospitalization course was complicated by cardiogenic shock, shock liver, acute renal failure, and sepsis.