Introduction: Muslims find it difficult to take L-thyroxine on empty stomach during Sahur. Furthermore, physiological changes during Ramadan alter thyroid hormones level. Objective: To compare the efficacy, safety and patient’s preference of weekly vs daily dosing of L-thyroxine in Ramadan. Method: This is a pilot randomized open-label controlled trial among hypothyroid patients during Ramadan 2017-2018. Patients were randomized into weekly and daily arm. Weekly arm took 7x their usual L-thyroxine dose at least 30 minutes pre-sahur once a week while daily arm took their usual daily dose at least 2 hours after the last meal before bed. Thyroid hormones, lipid profile, cardiac parameters, cognitive and psychological function were assessed at baseline and at week 4. Cardiac reassessment was done within 24hrs after weekly dosing at week 2. Results: Eighteen patients were randomized into weekly and daily arm. Majority (66.7%) were hypothyroid secondary to radioiodine therapy. At the end of study, there were no significant changes of thyroid hormones level for weekly arm. However there was significant increment of TSH observed in daily arm [TSH w0 1.8(0.23,5.57) vs w4 3.65(0.45,16.1);p =0.011]. In terms of toxicities, there were no hyperthyroid or cardiac toxicities observed despite the significant increment of fT4 within 24hours of weekly dosing [fT4 w0 13.21(8.19,14.63) vs w2 17.43(12.38,22.55);p=0.011]. All patients were euthyroid and had no side effects. Majority (83.3%) of patients preferred weekly dosing during Ramadan. Conclusion: Weekly levothyroxine dosing during Ramadan appeared to be safe, efficient and the most preferred dosing method.

Background: Infective endocarditis (IE) is an infection affecting the endocardial lining and contributed to socioeconomic burden due to prolonged admission, invasive procedure, and expensive treatment. The high prevalence of intravenous drug user intravenous drug user (IVDU) shifts the paradigm of the disease, and thus, we aim to determine the clinical characteristics, outcome, and inhospital mortality of IE among IVDU patients. Materials and Methodology: This is a retrospective cohort by analyzing case records for IVDU patients admitted to Hospital Tengku Ampuan Afzan diagnosed with IE from January 2014 until June 2017. Results: A total of 32 patients were included, with a median age of 35 years old (standard deviation: 6.5). Only 56.3% presented with fever, whereas most of them complained of nonspecific symptoms such as reduced exercise tolerance (59.4%) and weight loss (56.3%). Seventy-five percent had concomitant hepatitis C, but only 6.3% of them were HIV positive. Valvular heart disease accounted for 46.9%, while chronic rheumatic heart diseases and previous IE infection accounted for 28.1% and 18.8%, respectively. For microbiological characteristics, Staphylococcus aureus accounted for 62.5%, followed by streptococci (15.4%) and others (2%). The most common valve affected in IVDU was tricuspid valve (62.5%), followed by mitral valve (21.9%) and pulmonary valve (9.4%). Furthermore, mortality was reported at 25%, while severe valvular complications (62.5%) were observed with elevated episodes of emboli (62.5%) and cardiogenic shock (40.6%). Conclusion: Hence, IVDU is an essential predictive factor and is associated with various severe complications and thus warranted for aggressive preventive measurement to reduce the morbidity.

Introduction: Systolic Time Interval (STI) is a simple,noninvasive and precise technique to assess left ventricular (LV) function. It measures aortic Pre-Ejection Period (PEP) over Left Ventricular Ejection Time (LVET) from echocardiogram. Thyrotoxicosis will enhance LV function and cause reduction of STI.  This study was perform to measure the changes of STI after administration of high dose L-thyroxine and to determine the correlation between high dose L-thyroxine administration and STI. Materials and Method: A Total of 22 patients were screened. Those with cardiac diseases and high Framingham risk score were excluded. Nine patients were started on high dose L-thyroxine (7x their usual dose) once a week during the month of Ramadan.Thyroid hormones ( T3,T4,TSH)  and STI (PEP/LVET) were measured at baseline and within 24 hrs after high dose L-thyroxine ingestion. Results: All patients have normal thyroid hormones level and normal cardiac function at baseline. The median dose (mcg) of L-thyroxine was 600 (437.5,700) while the median level of fT4 (pmol/L) was 17.43(12.38,20.8). Despite the significant increment of fT4 after Lthyroxine ingestion [baseline 13.21(8.19,14.63) vs high dose 17.43(12.38,22.55) p; 0.011] there was no significant change in STI [baseline 0.3(0.2,0.4) vs high dose 0.28(0.26,0.45) p; 0.513]. There was no correlation found between the dose of Lthyroxine and STI (r=0.244 , p;0.526).  Conclusion: Administration of high dose Lthyroxine did not significantly alter STI despite significant increment of fT4 level unlike the naturally occurring thyrotoxicosis.Therefore ‘exogenous’ administration of high dose L-thyroxine is cardiac safe.