Patient characteristics, disease burden, treatment patterns and outcomes in patients with acromegaly: Real-world evidence from the Malaysian acromegaly registry / Journal of the ASEAN Federation of Endocrine Societies

Objective@#This study aims to report the demographic features of patients with acromegaly the disease burden, and the corresponding treatment patterns and outcomes in Malaysia.@*Methodology@#This is a retrospective study that included patients from the Malaysian Acromegaly registry who were diagnosed with acromegaly from 1970 onwards. Data collected included patient demographics, clinical manifestations of acromegaly, biochemical results and imaging findings. Information regarding treatment modalities and their outcomes was also obtained.@*Results@#Registry data was collected from 2013 to 2016 and included 140 patients with acromegaly from 12 participating hospitals. Median disease duration was 5.5 years (range 1.0 – 41.0 years). Most patients had macroadenoma (67%), while 15% were diagnosed with microadenoma. Hypertension (49.3%), diabetes (37.1%) and hypopituitarism (27.9%) were the most common co-morbidities for patients with acromegaly. Majority of patients had surgical intervention as primary treatment (65.9%) while 20.7% were treated medically, mainly with dopamine agonists (18.5%). Most patients had inadequate disease control after first-line treatment regardless of treatment modality (79.4%).@*Conclusion@#This registry study provides epidemiological data on patients with acromegaly in Malaysia and serves as an initial step for further population-based studies.

Effects of White Rice-Based Carbohydrates Diets on Body Weight and Metabolic Parameters in Rats

@#Introduction: We clarified the extent to which white rice (WR)-based carbohydrate diets affect body weight and metabolic parameters in rats. Methods: In this experimental study, a male Sprague Dawley (n=32) rats fed with WRbased CHO diet in two different proportions of total energy intake (TEI 55% moderate-CHO (MCHO, n=8) and 65% High-CHO (HCHO, n=8)) or high-fat diet (HFD, n=8) were compared with rats maintained on standard pellet diet (SD, n=8) for eight weeks period. Carbohydrate sources in the HFD and SD were mainly based on cornstarch (25% of amylose). Outcomes measures include body weight and metabolic parameters. Results: At baseline, body weight and metabolic parameters (fasting plasma glucose, insulin, and triglyceride levels) were comparable in all rats. Despite higher daily caloric intake in rats fed with HFD (103.9±3.0) than the other diets, no significant differences in body weight between groups after 8 weeks of study. However, rats’ feds with WR-based CHO diets (both moderate and high carbohydrates) had higher fasting blood glucose (MCHO=12.8±1.6, HCHO=16.9±2.4) and triglycerides level (MCHO=1.2±0.0, HCHO=1.3±0.0) than rats in cornstarch-based HFD and SD (p<0.05). Both HFD and HCHO had higher fasting insulin than MCHO and SD (p<0.05), but the homeostatic model assessment of insulin resistance (HOMA-IR) was significantly higher in WR-based CHO diets (both moderate and high carbohydrates) than the rats in cornstarch-based HFD and SD (p<0.05). Conclusion: A WR-based CHO diet exhibits higher fasting blood glucose, triglycerides, and insulin resistance state than a high-fat diet without a significant impact on body weight. These findings may explain the growing incidence of diabetes in Asia and worth studying further.

History of severe hypoglycemia in Type 2 Diabetes Mellitus Unmasked Significant Atherosclerotic Coronary Artery Disease: A comparative case control study / Journal of the ASEAN Federation of Endocrine Societies

Objectives@#A history of severe hypoglycemia (SH) is associated with cardiovascular (CV) events among patients with type 2 diabetes mellitus (T2DM). In this study, we compared the severity of atherosclerotic coronary artery disease (ACAD) in T2DM patients with and without a history of SH.@*Methodology@#We conducted a comparative case-control study involving 28 T2DM patients with a history of SH within the last 5 years with no documented ACAD, and matched them with 28 T2DM patients with no history of SH. All subjects underwent coronary artery calcium scoring (CACS) with or without coronary computed tomographic angiography (CCTA) to evaluate the severity of ACAD.@*Results@#A history of SH in T2DM was associated with a higher prevalence of significant ACAD (79% versus 46%, p=0.026). A high CACS (≥100) was seen in a greater number of patients with a history of SH compared to those without (75% versus 43%, p=0.029). Similarly, there was a higher prevalence of obstructive CAD in those with a history of SH compared to those without (72% versus 39%, p=0.036). Median C-reactive protein level was also higher among patients with a history of SH (0.41 mg/dL versus 0.16 mg/dL, p=0.029).@*Conclusion@#In patients with T2DM, a history of SH is significantly associated with ACAD compared to those without SH. A history of SH warrants screening for ACAD.

Treatment Options for Patients with Type 2 Diabetes Mellitus during the Fasting Month of Ramadan

During Ramadan, Muslims fast from sunrise (Sahur) to sunset (Iftar) and are required to abstain from food and fluids, including oral and injectable medications. Patients with diabetes who fast during Ramadan are at risk of developing hyperglycemia with increased risk of ketoacidosis, hypoglycemia, dehydration and thrombosis. Pre-Ramadan education and preparation of a fasting patient are essential to reduce severe complications. This review paper summarizes studies to date on oral and injectable medications available for patients with type 2 diabetes during Ramadan fasting, as well as recommendations on management of these patients during Ramadan. Although there is limited data on the use of Metformin, Acarbose and Thiazolidinedione in Ramadan, they appear to be safe. Sulphonylurea, especially Glibenclamide, is associated with higher risk of hypoglycemia during Ramadan fasting, hence may need adjustment in dosing and timing. The incretin group and SGLT2 inhibitor use during Ramadan fasting is associated with low risk of hypoglycemia with no increased adverse events. Insulin regimes need to be individualized for patients who fast during Ramadan.

Glycemic patterns and factors associated with Post-Hemodialysis Hyperglycemia among end-stage Renal Disease patients undergoing, maintenance Hemodialysis / Journal of the ASEAN Federation of Endocrine Societies

Introduction@#Chronic and post-prandial hyperglycemia are independent risk factors for diabetic complications. Glycemic patterns among hemodialysis end-stage-renal-disease (ESRD) differ as glucose metabolism changes with declining kidney function with more pronounced glycemic fluctuations. The objectives of this study are to determine glycemic patterns on hemodialysis days, the magnitude of post-hemodialysis rebound hyperglycemia (PHH) and their associated factors.@*Methodology@#148 patients on hemodialysis were analysed, 91 patients had end-stage-diabetic-renal disease (DM-ESRD), and 57 patients had end-stage-non-diabetic renal disease (NDM-ESRD). Glycemic patterns and PHH data were obtained from 11-point and 7-point self-monitoring blood glucose (SMBG) profiles on hemodialysis and non-hemodialysis days. PHH and its associated factors were analysed with logistic regression.@*Results@#Mean blood glucose on hemodialysis days was 9.33 [SD 2.7] mmol/L in DM-ESRD patients compared to 6.07 [SD 0.85] mmol/L in those with NDM-ESRD (p<0.001). PHH occurred in 70% of patients and was more pronounced in DM-ESRD compared to NDM-ESRD patients (72.5% vs 27.5%; OR 4.5). Asymptomatic hypoglycemia was observed in 18% of patients. DM-ESRD, older age, previous IHD, obesity, high HbA1c, elevated highly-sensitive CRP and low albumin were associated with PHH.@*Conclusion@#DM-ESRD patients experienced significant PHH in our cohort. Other associated factors include older age, previous IHD, obesity, high HbA1c, elevated hs-CRP and low albumin.

A case of appendiceal goblet cell carcinoid tumor: Getting it right under the microscope / Journal of the ASEAN Federation of Endocrine Societies

@#<p>Goblet cell carcinoid (GCC) is a rare neoplasm of the vermiform appendix and can be mistaken as a typical neuroendocrine tumour (TNET). The natural history of this disease is more aggressive compared to TNETs and requires a more aggressive approach. We report a case of a 37-year-old male who was initially diagnosed with TNET, but subsequently revised as Tang's A GCC. He underwent appendectomy and right hemicolectomy. Aside from a persistently elevated carcinoembyrogenic antigen (CEA) result, his 18F-fluorodeoxyglucose (FDG) PET/CT and a 68-Gallium DOTATATE PET/CT scan showed no FDG or DOTATATE avid lesions. </p>

A case of retroperitoneal liposarcoma mimicking an adrenocortical carcinoma / Journal of the ASEAN Federation of Endocrine Societies

@#<p style="text-align: justify;">An adrenal mass can be a diagnostic challenge as it is not easy to differentiate the adrenal glands from other adrenal pseudotumours with only radio-imaging. We report a 28-year-old patient who was diagnosed radiologically as an adrenal cortical carcinoma after he presented with abdominal pain and fullness. Biochemically, he demonstrated secondary hyperaldosteronism. Intra-operatively there was a huge mass, inferior to a normal right adrenal, which was histopathologically proven to be a dedifferentiated liposarcoma.</p>

Metastatic Bone Disease Secondary to Bronchial Adenocarcinomain a patient with Paget’s Disease of the Bone / Journal of the ASEAN Federation of Endocrine Societies

@#A 69-year-old female complained of intermittent left hip pain for the past 3 years. Biochemical tests revealed normal serum calcium and phosphorus with markedly raised alkaline phosphatase. MRI of the hip revealed extensive marrow signal abnormalities at the left pelvic bone, while CT of the thorax revealed a spiculated lung nodule at the left lower lung lobe. In order to diagnose either primary, metastatic bone tumour or Paget’s disease of the bone (PDB), an open biopsy of the left iliac bone was performed. The histopathology of bone biopsy of the left iliac bone was consistent with PDB. A CT guided biopsy of the lung mass done later revealed adenocarcinoma of the lung. She had 18F-FDG PET-CECT Scan for staging evaluation and result was suggestive of new bony metastases. Patient was started on IV Zoledronic acid for treatment of the PDB. In view of the stage 4 lung adenocarcinoma with bony metastases, patient was scheduled for palliative chemotherapy.

Successful primary medical therapy with somatostatin receptor ligand in acromegaly with thyroid cancer / Journal of the ASEAN Federation of Endocrine Societies

@#Acromegaly is a rare disease with an annual incidence of 3 to 4 cases in a million.[1] Diagnosis is often delayed due to the slow progression of the disease. Persistent elevation of growth hormone (GH) in acromegaly causes a reduction in life expectancy by 10 years. Aside from multiple cardiovascular, respiratory and metabolic co-morbidities, it has also been proven to cause an increased incidence of cancer. The main treatment of acromegaly is surgical excision of the functioning pituitary adenoma. Multiple comorbidities, including obstructive sleep apnea (OSA), left ventricular hypertrophy (LVH) and soft tissue swelling, make surgery complicated, if not impossible. Medical therapy to reduce co-morbidities may be indicated in certain situations. Somatostatin receptor ligands (SRL) are able to reduce, and possibly normalize, IGF-1 levels.[2] Reduction of insulin-like growth factor-1 (IGF-1), the main mediator of GH, is able to resolve headache, sweating, fatigue and soft tissue swelling, and also reduce ventricular hypertrophy. This case report illustrates the successful use of the SRL octreotide LAR in treating acromegaly. It also confirms the observation from several case series that thyroid cancer is the most common malignancy in acromegaly.

Reappraisal of bovril as a source of arginine in the arginine stimulation test for growth hormone deficiency

The purpose of this case study is to report the use of oral Bovril (a food supplement which contains arginine) as an alternative test for growth hormone stimulation test. We performed oral Bovril test in 3 patients -- one with suspected growth hormone deficiency in whom insulin tolerance test could not be performed (subject A), one sex-matched control (subject B), and one with confirmed growth hormone deficiency (subject C). 14g/m2 of oral Bovril was mixed with 150ml of warm water and was given to all three subjects. Blood for growth hormone was taken at baseline, and every 30 minutes till 150 minutes after ingestion of oral Bovril. The ingestion of oral Bovril showed a positive response in subjects A and B, with highest growth hormone levels of 28.4mIU/L and 42.0mIU/L respectively at 150 minutes. Subject C had suppressed growth hormone throughout the test. Oral Bovril is readily available and is a safe alternative for standard growth hormone stimulation test.

Utility of alpha-blockade in a hypotensive pheochromocytoma patient with myocardial infarction

The aim of this case study is to emphasize the importance of alpha-blockade in managing a rare complication of an untreated pheochromocytoma. Clinical Presentation and Intervention: A 41-year-old man with previous bilateral pheochromocytoma presented with chest pain. He was suffering from cardiac failure and persistent hypotension requiring an inotrope. Cardiac markers, an electrocardiogram and an echocardiogram confirmed acute myocardial infarct with poor ejection fraction and global hypokinesia. An [18]F-fluorodeoxyglucose PET/CT scan showed progressive left suprarenal and organ of Zuckerkandl pheochromocytomas. Blood pressure stabilisation proved challenging but was achieved by titrating an incremental dose of alpha-blocker against a tapering inotropic dose. This case showed the efficacy of an alpha-blocker despite persistent hypotension in a patient with pheochromocytoma-induced cardiomyopathy

Pheochromocytoma and Pregnancy: A Difficult and Dangerous Ordeal

Pheochromocytoma during pregnancy is potentially disastrous to the mother and fetus. Its ambiguous presentation is often mistaken for pre-eclampsia, although it may imitate other problems during pregnancy. Early diagnosis and timely, appropriate management reduces possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy; the condition was initially diagnosed as pre-eclampsia complicated with gestational diabetes. Surgical intervention via left adrenalectomy was successfully performed in the second trimester. After surgery, all of the patient’s medical problems nearly subsided and she did not require further treatment. However, her fetus displayed restricted intrauterine growth, and the patient eventually had premature delivery via a caesarean section. A multidisciplinary team to identify and treat pheochromocytoma is mandatory to ensure optimal conditions for tumour removal and to anticipate any possible catastrophic events.