RSS 1.0Diabetes and Endocrinology
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Semaglutide-associated drug-induced liver injury: a case report and review of the literatureSemaglutide is a glucagon-like peptide-1 receptor agonist (GLP-1RA) used to manage type 2 diabetes and, since 2021, for weight loss in individuals with obesity or weight-related comorbidities. It works by enhancing insulin secretion, delaying gastric emptying and reducing appetite. Common side effects include hypoglycaemia, gastrointestinal disturbances, nausea, weight loss and cholelithiasis. While some studies have noted an association with acute kidney injury, reports of liver injury are rare. We present a rare case of drug-induced liver injury in a middle-aged female, associated with transient liver failure after semaglutide use. She presented one month after starting the medication with rapidly worsening liver function tests. Investigations, including a non-invasive liver screen, viral studies, ultrasound and CT imaging, revealed no clear cause. A liver biopsy supported the diagnosis of drug-induced liver injury. The patient improved with supportive treatment and withdrawal of semaglutide. This case underscores the importance of clinician awareness given its increasing, and often unregulated, use for weight loss.
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A Case of Dual Secreting Adrenal Lesion With Multiple Complications Resulting From Hormonal Abnormalities.Introduction: Dual secreting adrenal tumours with catecholamine and ACTH secretion are rare. This dual secretion may alter the presentation of a Pheochromocytoma, which makes the diagnosis challenging [1]. Case report: A 47-year-old woman presented to the local emergency department with intermittent palpitations, abdominal pain and high blood pressure 220/96 mmHg.Investigation showed hypokalemia 3.0 mmol/L (3.5 - 5.3), and metabolic alkalosis (pH7.50, HCO3 32 mmol/L). A CT abdomen showed a 36 mm right adrenal lesion, which was initially reported as a myelolipoma by the local hospital. Plasma normetadrenaline 1.18 nmol/L (0 - 1.07), metadrenaline 0.88 nmol/L (0 - 0.33), and cortisol 2251 nmol/L were raised. She was started on spironolactone and phenoxybenzamine. Subsequent MRI showed a 3.4 cm right adrenal adenoma with cystic areas. ACTH was 156 ng/L (7.2-63.3) and 1mg overnight Dexamethasone suppression test failed to suppress serum cortisol. MRI pituitary was normal.Whilst awaiting outpatient review, the patient was re-admitted with DKA (new onset diabetes mellitus with high ketones and anion gap acidosis), and severe hypokalemia 1.4mmol/L, requiring critical care admission. She also required intubation and a broncho-alveolar lavage and was treated for pneumocystis jiroveci pneumonia (PJP). A discussion at the regional specialised endocrine MDT made a diagnosis of right pheochromocytoma with ectopic ACTH secretion with hyperplasia of the left adrenal gland, with no other clear source of ACTH on axial imaging, and high dose metyrapone initiated resulting in rapid control of the hypercortisolaemia. Autoantibodies for Type 1 diabetes mellitus were negative. On review at the regional endocrine centre, she was clearly Cushingoid, but with normal electrolytes, and maintained on medical therapy for 30 weeks to improve her clinical state prior to a right retroperitoneal adrenalectomy. Following this there was complete resolution of her clinical state and normalisation of plasma metanephrines, blood glucose, blood pressure, and plasma ACTH levels (30 ng/L) on no therapy. Histology showed a pheochromocytoma and adrenal cortical hyperplasia, although ACTH immunoreactivity was negative. Conclusion: This case highlights an unusual presentation of Cushing’s syndrome secondary to an ACTH-secreting pheochromocytoma (the challenges were absence of initial clinical signs of Cushing’s and borderline plasma metanephrine levels); complicated by new onset Diabetes Mellitus, DKA (in the absence of absolute insulin deficiency), and development of PJP [2]. Clinical resolution following surgery points towards the pheochromocytoma being the source of ACTH, as ACTH immunoreactivity may be negative. Normal pituitary morphology argues against ectopic CRH secretion.
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Monitoring thyroid function during amiodarone use.Amiodarone is an antiarrhythmic drug used to treat cardiac tachyarrhythmias. It has many adverse effects, with thyroid dysfunction one of the most notable. Through various mechanisms, both thyrotoxicosis and hypothyroidism can occur secondary to amiodarone therapy. There are two types of amiodarone-induced thyrotoxicosis: type 1 occurs in those with pre-existing thyroid disease and is treated with thionamide, whereas type 2 occurs in those without and is treated with glucocorticoids. Patients with amiodarone-induced hypothyroidism may be given levothyroxine to replace thyroid hormone, but in some cases, the appropriate management may be cessation of amiodarone.
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Amlodipine induced hyponatraemiaHyponatraemia (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.
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Tumour-induced osteomalacia.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.
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Considering the impact of patient ethnicity on cystic fibrosis related bone disease.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.
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Living with type 1 diabetes as a medical student.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.
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Non-training clinical fellowships.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.
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Association of the leptin receptor Q223R (rs1137101) polymorphism with obesity measures in Sri Lankans.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.
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Pharmacotherapy of type 2 diabetes mellitus in frail elderly patients.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.
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Acidophil stem cell pituitary adenoma: a case report and literature review.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.
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Acute Transient Stress Induced Adrenal Hypertrophy and Adrenal Medullary Hyperactivity.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.
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Energy and nutrient intakes of Sri Lankan patients with type 2 diabetes mellitus: a cross-sectional survey.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.
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Hypoglyceamia in a patient with a solitary fibrous tumour.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.
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Rising HbA1c in the presence of optimal glycaemic control as assessed by self-monitoring - iron deficiency anaemia.HbA1c can be affected by determinants other than glucose and an awareness of this is important to avoid unnecessary hypoglycaemia.
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Association of FTO and near MC4R variants with obesity measures in urban and rural dwelling Sri LankansObjectives: 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.
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Dysautonomia: An explanation for the medically unexplained?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.
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The Impact of a Decision Support Tool Linked to an Electronic Medical Record on Glycemic Control in People with Type 2 Diabetes.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.
