Recent Submissions

  • Amlodipine induced hyponatraemia

    Nuam, Cing San; Fernando, Devaka; Tun, Thein Zaw (Clinical Medicine, 2022-07)
    Hyponatraemia (serum sodium <135 mmol/L) is a common finding in clinical practice. Patients with hyponatraemia have increased morbidity and mortality compared with patients without hyponatraemia. Hyponatraemia is often iatrogenic and avoidable. These can be classified into 5 main types: hypovolaemic hyponatraemia, euvolaemic hyponatraemia, hypervolaemic hyponatraemia, hypertonic hyponatraemia and pseudohyponatraemia. Patients can be asymptomatic to severe cerebral oedema, leading to brainstem herniation, respiratory arrest and death.
  • Tumour-induced osteomalacia.

    Fernando, Devaka; Nuam, Cing San; Tun, Thein Zaw (Clinical Medicine Journal, 2022-07)
    Phosphate is important for normal mineralisation of bone. Phosphate is important in its own right for neuromuscular function, and profound hypophosphataemia can be accompanied by encephalopathy, muscle weakness and cardiomyopathy. Hypophosphataemia can be due to intracellular uptake of phosphate from the extracellular fluid, reduced intestinal phosphate absorption, increased renal excretion, decreased renal tubular absorptive capacity and genetic defects in renal tubule phosphate transporters.
  • Considering the impact of patient ethnicity on cystic fibrosis related bone disease.

    Akbari, Amir R (Journal of Clinical & Translational Endocrinology, 2022-07)
    We found the article “Bone accrual and structural changes over one year in youth with cystic fibrosis” by Rosara M.Bass et al [1] to be of great interest. The study investigated bone changes over one year in individuals aged 5–18 with both cystic fibrosis (CF). The aim of this was to see how much bone development in youth and emerging adults contributes to cystic fibrosis related bone disease (CFBD). The study accounted for the following patient demographics: weight, height, age, pubertal status, and gender [1]. Although these are important factors, we believe it is important to consider the impact of patient ethnicity on the development of structural changes in the bone. Several studies across western countries have found that vitamin D deficiencies are more prevalent in ethnic minority groups, including South Asian and Black African-Caribbean populations [2], [3]. This is thought to be due to skin pigmentation being a factor which impacts the levels of vitamin D produced in the skin after sun exposure [2]. Furthermore, vitamin D deficiency is also the most recognised cause of CFBD [4]. Therefore, it is important to recognise the potential impact of ethnicity on changes in bone development in patients with CF. Additionally, it is important to note that studies have demonstrated that CF patients from ethnic minority backgrounds are more likely to experience worse outcomes compared to white patients [5]. For example, a study in the United States found that Hispanic and Black patients with CF had worse respiratory function compared to white patients [5]. We therefore propose that future studies should include ethnicity as a patient demographic. Further research into the impact of ethnicity on CFBD will enable a more inclusive and holistic approach towards diagnosis and treatment of CF.
  • Living with type 1 diabetes as a medical student.

    Smith, Chloe (BMJ, 2022-04)
    I was diagnosed with type 1 diabetes when I was 17, just days after finishing my A level exams. I had lost 5kg in weight and experienced extreme thirst and tiredness over the previous few weeks, but I put that down to exam stress and was looking forward to recovering over the summer. “Luckily,” my very elevated blood glucose levels were picked up on a routine blood test before I went into diabetic ketoacidosis. In one day, I went from a normal 17 year old, preparing to apply to medical school, to someone with a chronic illness, controlled by multiple injections and finger pricks a day.
  • Neonatal hyperinsulinaemic hypoglycaemia and early onset diabetes secondary to biallelic ABCC8 (MODY 12) mutation

    Larsen, N; Chaw, K; Khan, S (British Journal of Diabetes. Conference: Association of British Clinical Diabetologists Conference, ABCD 2020, 2021)
  • Non-training clinical fellowships.

    Fernando, Devaka; Smith, Daniel; Cox, Giles; Haynes, Andrew; Dharmarajan, Venoden; Noor, Muhammed (Future Healthcare Journal, 2019-06)
    Editor – We read with interest the paper by Jalal et al.1 Sherwood Forest Hospitals, has provided non-training clinical fellowships since 2002.2 An account of how it addresses the issues raised in the paper by Jalal et al has been reported.3 Many overseas doctors are trained through traditional undergraduate medical curricula which do not emphasise communication and leadership skills, in contrast to significant emphasis on communication and leadership skills in the UK. It is a significant cultural shift for them to make the transition to settings where skills of communication and teamwork are given high priority in the clinical setting and assessed through work place based assessments using an electronic portfolio. Our programme addressed this challenge through 8 weeks of a supervised supernumerary period in a supported environment, designed to expose the clinical fellows gradually to the work environment through an extended period of induction mentoring and coaching with a gradual transition to the new work environment to enable the fellows overcome language, communication, clinical and work-cultural challenges and adapt to the UK healthcare system. Overseas doctors, who are employed in non-training positions, do not by right receive the training and educational opportunities offered to trainees in the National Training Programme and are not monitored by the Guardian for Safe Working Hours. Our programme addressed this issue by providing a study leave allocation, protected time for personal and professional development as well as deployment of the gripes tool.4 Leadership, management and educational governance of the Clinical Development Fellowship Programme is through a committee comprising the executive medical director, director of postgraduate medical education and senior human resources staff. The success of the programme was reflected in the programme outcomes which showed that 49% of fellows gained a training grade post and another 19% appointed to trust grade posts with responsibility at registrar grade during or at the end of the programme. The programme has also shown a reduction in variable pay costs as well as overall costs of employing non-training grade junior doctors. Introduction of the programme has resulted in a fall in both the total spend and spend on agency employed locum doctors.
  • Association of the leptin receptor Q223R (rs1137101) polymorphism with obesity measures in Sri Lankans.

    Fernando, Devaka (2020-01-16)
    Objective: The role of genetic factors in the development of obesity is largely unreported in Sri Lankans. The Q223R (rs1137101) single nucleotide polymorphism (SNP) of the leptin receptor (LEPR) gene has been associated with obesity measures in various ethnicities. We investigated the association of the Q223R polymorphism with obesity related anthropometric measures and biochemical parameters fasting blood glucose and lipid profile in a sample of 530 Sri Lankan adult subjects (age 18-70 years) representing both urban and rural areas of residence. Results: The LEPR Q223R variant G allele frequency was 0.54. The polymorphism was associated with body mass index (p = 0.04) and waist circumference (p = 0.02) measures in overweight and obese (BMI ≥ 25 kgm -2 ) subjects with the variant allele conferring a greater risk of adiposity. Residency in urban areas eliminated the protective effect of the non-risk genotype (AA) in the development of obesity.
  • Pharmacotherapy of type 2 diabetes mellitus in frail elderly patients.

    Sathyanarayanan, Abilash; Rabindranathnambi, Aswatha; Muraleedharan, Vakkat (2019-12)
    The prevalence of type 2 diabetes mellitus is expected to rise in the frail elderly population, which will have significant consequences for the health economy. Symptoms of hypoglycaemia can be subtle in the elderly. Hypoglycaemia accounts for more hospital admissions than hyperglycaemia. Treatment targets are set based on the risk of adverse events resulting from treatment and the benefits expected from tighter glycaemic control. The different medications available are discussed including the different types of insulin, in particular relation to usage in older adults. The choice of therapy is based on the targets, comorbidities and the characteristics of each antidiabetic agent. Deintensification of therapy should be considered in patients who experience adverse effects. Treatment guidelines should be formulated based on the above principles, as many current guidelines do not incorporate deintensification of therapy.
  • Acidophil stem cell pituitary adenoma: a case report and literature review.

    Rathi, Manjusha (2019-12)
    In this article, we describe a very rare case of pituitary acidophilic stem cell adenoma, accompanied by a literature review. We present the case of 33-year-old woman with a history of amenorrhea, galactorrhea, elevated prolactin levels, and pituitary tumor. Despite suppression of prolactin levels with cabergoline, the pituitary tumor continued to increase in size and the patient developed clinical symptoms and biochemistry consistent with the diagnosis of acromegaly due to acidophilic stem cell adenoma, an extremely rare subtype of mixed growth hormone/prolactin adenoma, which behaves more aggressively and has a lower surgical cure rate compared to the pure GH-secreting adenoma. The patient had in vitro fertilization 2 years after the successful pituitary surgery and delivered healthy twins. To our knowledge, this is the only case report which describes acromegaly developing during cabergoline treatment. This case also highlights the importance of having a correct histopathological diagnosis to determine the behavior of the tumor and decide on further management.
  • Acute Transient Stress Induced Adrenal Hypertrophy and Adrenal Medullary Hyperactivity.

    Aarella, Vikram; Fernando, Devaka; Mudenha, Emily; Okpe, Andrew (2015)
    Objectives: Adrenal gland hypertrophy can be related to acute stress with abnormal adrenal function tests. It may not always need treatment. Material and methods: An acute presentation of adrenal gland hypertrophy following an abdominal emergency, with subsequent hypoadrenalism was investigated. Results: Adrenal medullary and cortical function fully recovered without treatment. Conclusions: We postulate that the adrenal glands became enlarged and hypertrophied during an acute stress event, possibly caused by acute adrenal medullary hypersecretion and subsequent cortical hyposecretion. A wait and watch policy should be followed if no other clinical symptoms and signs of adrenal disease are present. CT scan remains an important diagnostic tool.
  • Energy and nutrient intakes of Sri Lankan patients with type 2 diabetes mellitus: a cross-sectional survey.

    Fernando, Devaka (2015-08-12)
    Background: Sri Lanka has a high prevalence of type 2 diabetes mellitus. Energy and macronutrient intakes of diabetic patients have not been previously studied in this population. We aimed to clarify the energy and nutrient intakes among a group of type 2 diabetic patients attending a tertiary care diabetes facility in Sri Lanka. Methods: Nutritional and energy intake of 123 randomly selected patients with type 2 diabetes, aged 30-74 years was assessed using a 24-h dietary recall. Results: The mean energy intake for all participants was 1438 (SD 412) Kcal/day. The mean proportions of total carbohydrate, protein and fat comprising total energy intake were 68.1, 11.5 and 20.2 % respectively. The mean carbohydrate intake of 249.7 g/day comprised 50 % of rice. The mean daily protein, fat and dietary fibre intake was 42.5, 33 and 18.1 g respectively with a major contribution from plant sources. There was no significant difference in energy and nutrient intakes among the male and female participants. Conclusion: The present study provides the first pilot data on the energy and macronutrient intakes of diabetes patients in Sri Lanka. We clarified that these patients consumed an energy restricted, high-carbohydrate low fat diet compared to western diabetic patients. A larger nationwide dietary survey is recommended to confirm our findings.
  • Hypoglyceamia in a patient with a solitary fibrous tumour.

    Okpe, Andrew; Ramsay, Kerri; Fernando, Isuru; Fernando, Devaka; Mudenha, Emily (2016-04)
    Objective: To illustrate an unusual mechanism causing hypoglycaemia. Material and methods: A 76-year-old man presented with episodes of agitation and confusion and was resuscitated with oral glucose gel when found to be hypoglycaemic. Results: A CT scan for an abdominal mass confirmed a solitary fibrous tumour (SFT). The sarcoma multidisciplinary team suggested conservative management. The patient's episodic hypoglycaemia was managed with diet modification including corn-based starch, scheduled snacks and dexamethasone. Glucose levels were within normal range at discharge from hospital. The patient was referred to the palliative care team for follow-up. Conclusion: SFTs causing non-islet cell tumour hypoglycaemia are difficult to treat., Copyright © EFIM 2015.
  • Rising HbA1c in the presence of optimal glycaemic control as assessed by self-monitoring - iron deficiency anaemia.

    Mudenha, Emily; Aarella, Vikram; Chandrasekaram, Senthil; Fernando, Devaka (2016-02)
    HbA1c can be affected by determinants other than glucose and an awareness of this is important to avoid unnecessary hypoglycaemia.
  • Association of FTO and near MC4R variants with obesity measures in urban and rural dwelling Sri Lankans

    Fernando, Devaka (2016-09)
    Objectives: To investigate the association between the fat mass and obesity related (FTO) gene rs9939609 and near melanocortin-4-receptor (MC4R) gene rs17782313 polymorphisms with obesity measures and metabolic parameters in urban and rural dwelling Sri Lankans. Methods: 535 subjects (60.9% female) from the general adult population (ages 18-70 years) representative of both urban (28.4%) and rural areas of residence were recruited by multi-stage random sampling. Body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) was obtained by standard methods. DNA extracted from whole blood was genotyped using real-time PCR. Results: The FTO risk genotypes (AA + AT) were associated with higher BMI (p = 0.03) and WC (p = 0.05) measures as well as categorical obesity (BMI >= 27.5 kg m(-2) definition) (OR 1.69 95% CI 1.11-2.56, p = 0.01). The near MC4R risk genotypes (CC + CT) were associated with greater BMI (p = 0.03) as well as categorical obesity (BMI >= 25 kg m(-2) definition) (OR 1.57 95% CI 1.11-2.22, p = 0.01). In addition the MC4R risk genotype carriers (CC + CT) had significantly higher fasting blood sugar (FBS) levels compared to the 'TT' genotype carriers independent of BMI (p = 0.05). Urban living was associated with significantly greater BMI values for FTO risk genotypes compared to rural living (p = 0.02). Conclusions: FTO and near MC4R variants are associated with obesity measures in Sri Lankan populations whilst urban living accentuates the obesogenic effect of the FTO polymorphism. (C) 2016 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
  • Dysautonomia: An explanation for the medically unexplained?

    Chandrasekaram, Senthil; Aarella, Vikram; Mudenha, Emily; Fernando, Devaka (2016)
    Objective: To identify dysautonomia as a collection of conditions with variable presentation that may be mistaken for medically unexplained symptoms. Methods: Case series. Results: Tilt table testing and 24 h electrocardiographic monitoring provided useful diagnostic tools to confirm the diagnosis. Conclusion: A greater awareness and recognition of the disorders that result from dysautonomia and recognition of the disability that results from these disorders will improve patients' quality of life., Copyright © EFIM 2015.
  • The effect of using a shared electronic health record on quality of care in people with type 2 diabetes.

    Parker, Rebecca; Hassoun, Salman; Miles, Sylvia; Fernando, Devaka (2014-09)
  • The Impact of a Decision Support Tool Linked to an Electronic Medical Record on Glycemic Control in People with Type 2 Diabetes.

    Gunathilake, Waruna; Fernando, Devaka (2013-05)
    Aims: We retrospectively compared glycemic control and glycemic burden in type 2 diabetes patients treated by general physicians with access to decision support with those treated by general physicians without access to decision support. Methods: A total of 875 patients [471 (53.8%) males] aged 54.3 [standard deviation (SD) 13.1] years followed up over 84 months. A total of 342 patients (39%) were managed with decision support, and effects on glycosylated hemoglobin (HbA1c) were assessed. Results: There was no difference between groups in starting HbA1c [7.6 (SD 1.8) versus 7.5 (SD 1.5); p = not significant] at baseline. Patients treated with decision support were more likely to have planned review of HbA1c, adjustment of medication, prescription of statins, dietetic and nurse educator inputs (71.3% versus 58.5%; Chi squared = 14.7; p = .001). The mean HbA1c in the group treated with decision support was not significantly reduced within the first year [7.5% (SD 1.8) versus 7.6% (SD 1.5); p = not significant; 95% confidence interval (CI) -0.33 to 0.17], but statistically significant differences were apparent at year 2 [7.2% (SD 2.0) versus 8% (SD 3.4); p = .0001; 95% CI -1.3 to -0.5] and sustained through year 3 [7.2% (SD 2.0) versus 8.0% (SD 2.0); p = .0001; 95% CI -1.2 to -0.6], year 4 [7.2% (SD 2.3) versus 8.2% (SD 2.5); p = .0001; 95% CI -1.2 to -0.6], year 5 [7.0% (SD 2.3) versus 8.3% (SD 2.6); p = .001; 95% CI -1.5 to -0.8], year 6 [7.0% (SD 2.0) versus 8.2% (SD 2.4); p = .001; 95% CI -1.5 to -0.9], and year 7 [6.9% (SD 1.2) versus 8% (SD 1.8); p = .001; 95% CI -1.4 to -1.0]. Conclusion: Use of a decision support system showed benefits in adherence to clinical care pathways and achieving significant improvements in glycemic control.
  • Exenatide improves excessive daytime sleepiness and wakefulness in obese patients with type 2 diabetes without obstructive sleep apnoea.

    Idris, Iskandar; Abdulla, Haitham; Tilbrook, Sean; Dean, Roy; Ali, Nabeel (2013-02)
    We investigate the effects of exenatide on excessive daytime sleepiness (EDS), driving performance and depression score in patients with type 2 diabetes with EDS. Eight obese patients with diabetes but without obstructive sleep apnoea (OSA) participated in a placebo-controlled single-blind study during which multiple wakefulness and sleep latency test, Epworth score, driving performance, depression score, fasting glucose and glycated haemoglobin (HbA1c) levels were assessed at baseline, end of placebo and treatment phase at baseline and after 22 weeks of treatment. Mean (±standard error of the mean) age, body mass index (kg m2) and HbA1c [mmol mol−1 (%)] of patients at baseline were 50 ± 4.9 years, 37.6 ± 1.1 and 65 ± 19 (8.06 ± 0.41), respectively. When compared to placebo, exenatide treatment was associated with a decrease in both subjective and objective sleepiness, based on the Epworth score reduction and the sleep latency increase assessed by multiple objective sleepiness and sustained attention (OSLER) tests, respectively. Mean sleep latency time (adjusted for change in HbA1c and weight) were 32.1 ± 1.7, 29.1 ± 1.7 and 37.7 ± 1.7, respectively ( P = 0.002). Modelling for covariates suggested that improvement in mean sleep latency time is predicted by changes in weight ( P = 0.003), but not by changes in HbA1c ( P = 0.054). Epworth sleepiness score was reduced significantly (values for placebo versus exenatide: 11.3 ± 1.2 versus 5.7 ± 1.3; P = 0.003). No significant change was noted in the depression score and driving performance. Exenatide is associated with a significant reduction in objective sleepiness in obese patients with type 2 diabetes without OSA, independent of HbA1c levels. These findings could form a basis for further studies to investigate the pathophysiological mechanisms of sleepiness in obese patients with type 2 diabetes.
  • A prospective longitudinal study of Pasireotide in Nelson's syndrome.

    Girio-Fragkoulakis, Constantine (2018-01)
    PURPOSE: Nelson's syndrome is a challenging condition that can develop following bilateral adrenalectomy for Cushing's disease, with high circulating ACTH levels, pigmentation and an invasive pituitary tumor. There is no established medical therapy. The aim of the study was to assess the effects of pasireotide on plasma ACTH and tumor volume in Nelson's syndrome. METHODS: Open labeled multicenter longitudinal trial in three steps: (1) a placebo-controlled acute response test; (2) 1 month pasireotide 300-600 μg s.c. twice-daily; (3) 6 months pasireotide long-acting-release (LAR) 40-60 mg monthly. RESULTS: Seven patients had s.c. treatment and 5 proceeded to LAR treatment. There was a significant reduction in morning plasma ACTH during treatment (mean ± SD; 1823 ± 1286 ng/l vs. 888.0 ± 812.8 ng/l during the s.c. phase vs. 829.0 ± 1171 ng/l during the LAR phase, p < 0.0001). Analysis of ACTH levels using a random intercept linear mixed-random effects longitudinal model showed that ACTH (before the morning dose of glucocorticoids) declined significantly by 26.1 ng/l per week during the 28-week of treatment (95% CI - 45.2 to - 7.1, p < 0.01). An acute response to a test dose predicted outcome in 4/5 patients. Overall, there was no significant change in tumor volumes (1.4 ± 0.9 vs. 1.3 ± 1.0, p = 0.86). Four patients withdrew during the study. Hyperglycemia occurred in 6 patients. CONCLUSIONS: Pasireotide lowers plasma ACTH levels in patients with Nelson's syndrome. A longer period of treatment may be needed to assess the effects of pasireotide on tumor volume.