Primary hyperparathyroidism in pregnancy: experience of a tertiary centre.

BACKGROUND AND PURPOSE: The management of primary hyperparathyroidism (PHPT) during pregnancy is challenging and there is no clear consensus on whether it increases the risk of complications in pregnancy. We conducted this study to review the maternal and fetal outcomes of pregnant women treated for PHPT in a single centre. METHODS: Data on relevant clinical parameters, demographics, management strategies, maternal and fetal outcomes were collected from the medical records of pregnant patients with PHPT diagnosed between 2012 and 2019. RESULTS: Of 15 pregnant women with PHPT, 6 were managed medically and 9 underwent surgery. The median age at their index pregnancy was 28 years [range 19-42]. The median highest adjusted calcium level in the medical group was 2.90 [range 2.61-3.25] mmol/L vs. 3.11 [2.78-4.95] mmol/L in the surgical group. There was one miscarriage and the stillbirth of twins in the medical group, but no such outcomes in the surgical group. The median gestational ages were 39 + 3 weeks [range 24 + 2-41 + 2 weeks] and 39 + 4 weeks [range 37 + 1-39 + 5 weeks] in the medical and surgical groups, respectively. No birth was complicated by neonatal tetany or convulsions. CONCLUSION: More complications developed in the pregnant PHPT patients who were managed medically than in those who underwent surgery. Surgery performed during the second trimester resulted in good outcomes. Multi-centre prospective studies are required to ascertain the risk of various complications in women with PHPT during pregnancy.

Prevalence of Depression and Associated Factors among Patients with Type 2 Diabetes Attending the Diabetic Clinic at a Tertiary Care Hospital in Sri Lanka: A Descriptive Study.

BACKGROUND: Research focusing on the psychological aspect of diabetes is limited in Sri Lanka. AIM: Determine the prevalence of depression among patients with type 2 diabetes mellitus (T2DM) attending an out-patient clinic at a tertiary care hospital in Colombo, the capital of Sri Lanka. METHODS: A descriptive cross-sectional study carried out among patients diagnosed with T2DM. Pregnant and patients with a prior psychiatric history were excluded. Depression assessed using validated Sinhala and Tamil version of the Beck's Depression Index. Sociodemographic data and health related data were obtained from interviewer-based questionnaires and health records. RESULTS: Of the 3000 patients, 72.7% were female. Mean age was 58.3 ±10.3 years and mean duration of diabetes 10.8 ± 7.3 years. Percentage of depression was 5.9% in the entire patient population with mild, moderate, and severe depression in 4.0%, 1.6%, and 0.3%, respectively. In multiple logistic regression, depression was significantly associated with female gender (OR 2.63, 95% CI 1.26-5.46; P=0.009), living without a spouse (single/divorced/widowed) (OR 1.83, 95% CI 1.12-2.98; P=0.01), lower education level (OR 1.92, 95% CI 1.14-3.22; P=0.01), and peripheral neuropathy (OR 1.79, 95% CI 1.00-3.18; P=0.04). Only 13.3% of the respondents said that doctors have ever inquired to their mental well-being. CONCLUSION: Depression was low in prevalence comparative to neighboring countries in the region. Patients were much more affected by the social factors than disease related factors. An individualized holistic approach taking psychosocial issues to consideration should be focused in the comprehensive plan of management.

Prevalence of Chronic Complications, Their Risk Factors, and the Cardiovascular Risk Factors among Patients with Type 2 Diabetes Attending the Diabetic Clinic at a Tertiary Care Hospital in Sri Lanka.

Diabetes incurs heavy burden to patients and the healthcare system. Assessment of disease burden is important in taking necessary precautions and management decisions. We aimed to determine the prevalence of macro- and microvascular complications, their risk factors, and coronary artery disease (CAD) risk factors among patients with type 2 diabetes mellitus (T2DM). A descriptive cross-sectional single-centre study was carried out among 3000 patients with T2DM attending the diabetic clinic at the National Hospital of Sri Lanka from January to July 2016. The study population had 72.7% females and 27.3% males. Mean age and disease duration were 58.3 ± 10.3 and 10.8 ± 7 years, respectively. Prevalence of CAD, stroke, and peripheral vascular disease were 10.6%, 1.1%, and 4.7% while diabetic retinopathy, neuropathy, nephropathy, diabetic foot, and lower extremity amputation (LEA) were 26.1%, 62.6%, 50.8%, 2.6%, and 1.3%, respectively. Prevalence of overweight/obesity, hypertension, dyslipidemia, and smoking were 80%, 77.6%, 76.7%, and 11%, respectively. Increased age, disease duration, and HBA1c were risk factors for microvascular disease and diabetic foot while age was the only risk factor for macrovascular complications. Occurrence of CAD, peripheral neuropathy, diabetic foot, and LEA was significantly higher among males than when compared to females. This study highlights the major burden of chronic complications and high prevalence of CAD risk factors in this population.

Case report: rare skeletal manifestations in a child with primary hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (PHPT) is uncommon among children with an incidence of 1:300,000. This diagnosis is often missed in children in contrast to adults where it is detected at a pre symptomatic stage due to routine blood investigations. Etiology of PHPT can be due to adenoma, hyperplasia or rarely carcinoma. CASE PRESENTATION: A 12 year old Sri Lankan girl presented with progressive difficulty in walking since 1 year. On examination she had bilateral genu valgum. Skeletal survey revealed valgus deformity of knee joints, bilateral subluxation of upper femoral epiphysis(SUFE), epiphyseal displacement of bilateral humeri, rugger jersey spine and subperiosteal bone resorptions in lateral aspects of 2nd and 3rd middle phalanges. There were no radiological manifestations of rickets. Metabolic profile revealed hypercalcemia with hypophosphatemia. Intact parathyroid hormone levels were elevated at 790 pg/ml. Vitamin D levels were deficient. She had low bone mineral density with Z score of -3.4. Vitamin D supplementation resulted in worsening of hypercalcemia without reduction in PTH levels. Tc 99 Sestamibi uptake scan showed abnormal tracer retention in left inferior pole of thyroid. A large parathyroid gland was removed with histology favoring parathyroid adenoma. Post operatively she developed hypocalcemia. Bilateral osteotomy was done for SUFE and further surgeries for correction of limb deformities planned. CONCLUSION: PHPT in children is usually diagnosed late when irreversible organ damage has occurred. Children can present with non specific symptoms involving gastrointestinal, musculoskeletal, renal and neurological systems. PHPT can cause disarray in bone and epiphysis in children during pubertal growth spurt. Genu valgum and SUFE are rare skeletal manifestations in PHPT and only 10 cases of genu valgum and 9 cases of SUFE have been reported up to now. So far no cases have been reported on epiphyseal displacement of humeri. Awareness regarding the occurrence of these rare skeletal manifestations especially during puberty is important for early diagnosis to prevent irreversible outcomes.

Extreme hypernatremia as a probable cause of fatal arrhythmia: a case report.

BACKGROUND: Hypernatremia is a frequent occurrence among hospitalized patients. Severe hypernatremia is associated with mortality rates of over 60 %. Extreme hypernatremia, defined as sodium levels >190 mmol/l, is a rare occurrence. The literature on electrocardiographic changes occurring with this degree of hypernatremia is extremely scarce. We report the case of an 11-year-old Sri Lankan girl who presented with sodium levels of 226 mmol/l following infusion with 3 % hypertonic saline who developed diffuse QT prolongation leading to fatal ventricular tachycardia. CASE PRESENTATION: An 11-year-old Sri Lankan girl presented with fever, headache, vomiting, and altered level of consciousness. Following admission she developed generalized tonic-clonic seizures and was intubated and ventilated. She had a recent history of polyuria and polydipsia. Magnetic resonance imaging of her brain revealed hydrocephalus due to possible craniopharyngioma. A ventriculoperitoneal shunt was inserted and she was infused with 3 % hypertonic saline in an attempt to reduce intracranial pressure. The following day she became polyuric and dehydrated with tachycardia and low blood pressure. Biochemistry revealed serum sodium of 226 mmol/l, measured serum osmolality of 470 mOsm/kg, urine osmolality of 280 mOsm/kg, urine spot sodium of 116 mmol/l, blood urea of 8.1 mmol/l, and blood glucose of 8.5 mmol/l. Her serum potassium, calcium, and magnesium levels were normal. Extreme hypernatremia due to infusion of 3 % hypertonic saline in the background of cranial diabetes insipidus was considered. She was managed aggressively with 5 % dextrose infusion and clear water via nasogastric feeding to correct the fluid deficit of 7 liters over 36 hours. Her sodium levels dropped to 160 mmol/l the following day. However, she developed electrocardiographic changes with widespread gross QT prolongation with ST segment deviations followed by fatal ventricular tachycardia. CONCLUSIONS: Extreme hypernatremia is rare, and the literature on electrocardiographic changes occurring at such high levels of sodium is scarce. At present there are no established guidelines on rate and mode of correction of such high sodium levels. This case highlights the electrocardiographic changes observed during extreme hypernatremia, controversies in managing increased intracranial pressure with hypertonic saline, and dilemmas encountered in managing extreme hypernatremia.