Occurrence of Immune Thrombocytopenic Purpura Following Enucleation of a Neuroendocrine Tumor of the Head of the Pancreas

Neuroendocrine tumors are growths occurring in various organs including the pancreas which contain endocrine tissue. Pancreatic neuroendocrine tumors are rare in occurrence with an incidence of <1 per 100,000 individuals. But the incidence is rising and the said tumors are becoming more common in the world. Herein we report a case of a 49-year-old female with a background history of poorly controlled type 2 diabetes mellitus for 7 years, dyslipidemia, and bronchial asthma for 19 years on regular inhaler therapy presenting with a history of back pain for 3 months duration. With serial investigations, she was found to have a neuroendocrine tumor involving the head of the pancreas with no local infiltration and distant metastases. Whipple's procedure was performed after which she developed thrombocytopenia from post-operative day 1 itself. Following this, she was diagnosed as having immune thrombocytopenic purpura and being managed with oral corticosteroids, after which she made a successful recovery from the acute condition but with multiple relapses from time to time.

Utilization of statins in patients with type 2 diabetes mellitus: the practice in a lower middle income South Asian country

Background

Cardiovascular disease (CVD) is a major cause of morbidity and mortality among patients with type 2 diabetes. Statin reduces CVD risk. The ACC/AHA 2018 guideline on dyslipidemia recommends all patients with type 2 diabetes mellitus to be given moderate-intensity statin. We aimed to determine the prescription practices of statins among patients with type 2 diabetes mellitus.

Methods

A cross-sectional study was conducted from February to April 2021. Patients with type 2 diabetes mellitus between 40 and 75 years were recruited from the University Medical Clinic and Endocrine Clinic at Colombo South Teaching Hospital, Sri Lanka.

Results

Four hundred seventy-one patients were enrolled with a mean age of 59.05 (± 9.139) years. The mean duration of diabetes was 10.97 (± 9.57) years. Four hundred forty-one (93.6%) patients were on statin and 30 (6.4%) patients were not on statin therapy. Those not on statins were not prescribed statins.

Conclusions

There were 163 (34.61%) patients who required high intensity. Though only 3 (1.73%) were on high-strength statin, the rest were on moderate (152, 93.25%), low (4, 2.45%), and none (4, 2.45%). Among patients with prior history of atherosclerotic cardiovascular disease (ASCVD) and the high-risk category according to the 10-year ASCVD risk estimation (155, 32.91%), only 17 (10.97%) have achieved optimal LDL therapeutic targets (55mg/dL). A large proportion of the study population received statin therapy for primary and secondary prophylaxis. However, the majority were on suboptimal doses of statin and have not achieved therapeutic targets with regard to LDL-C levels. The findings highlight the importance of improving statin therapy and optimizing lipid management according to evidence-based guideline recommendations.

Seeking the unseen: Localization and surgery for an occult sporadic insulinoma

Insulinomas are rare pancreatic neuroendocrine tumours and the commonest cause for endogenous hyperinsulinaemic hypoglycemia. Small tumours are not easily detected by conventional cross-sectional imaging making localization prior to surgical removal a challenge. Selective arterial calcium stimulation is an invaluable adjunct to localization in such circumstances. This is further supplemented by intraoperative ultrasonography. A 39-year-old male was referred with features of Whipple’s triad of 10 months duration. Clinical and biochemical evaluation including C-peptide and serum insulin levels during supervised hypoglycemia concluded endogenous hyperinsulinaemia as the underlying aetiology. Contrast CT and MRI of the abdomen failed to localize the tumour. Selective arterial calcium stimulation localized the lesion in distal pancreas. During the surgery, tumour was further localized to the tail of the pancreas using intraoperative ultrasonography and enucleated. Histology confirmed an insulinoma and patient made an unremarkable recovery and was well more than a year after the surgery.

Glucocrinology of Modern Sulfonylureas: Clinical Evidence and Practice-Based Opinion from an International Expert Group

AIM

The primary objective of this document is to develop practice-based expert group opinion on certain important but less discussed endocrine and metabolic effects of modern sulfonylureas (SUs) and their usage in the management of diabetes mellitus (DM).

BACKGROUND

Modern SUs may be considered a panacea in DM care with their beneficial extra-pancreatic, pleiotropic, and cardiovascular effects. Safe glycemic control with SUs could be achieved with appropriate patient selection, drug and dosage selection, and patient empowerment. Additionally, sulfonylureas also exhibit certain endocrine and metabolic effects, which could be considered beneficial in the management of DM. In this regard, a group of international clinical experts discussed the less known beneficial aspects of SUs and safe and smart prescription of modern SUs in DM care.

RESULTS

The concept of glucocrinology or the relationship of glycemia with the endocrine system was emphasized during the meetings. Clinical experts arrived at a consensus for the usage of modern SUs in the presence of other endocrine dysfunction and the impact of these drugs on endocrine health. The beneficial pleiotropic and cardiovascular effects of modern SUs were also discussed. The key discussion points were considered to develop clinical expert opinions for the use of modern SUs in persons with DM. Clinical expert opinions were developed for indications, pleiotropic benefits, cardiovascular outcomes, adherence, and safe use of modern SUs.

CONCLUSIONS

Appropriate clinical judgement coupled with a patient-centered approach is crucial to achieve the best outcome in persons with DM. Owing to their safety, efficacy, extra-pancreatic benefits including effects on endocrine and metabolic aspects, and low cost of therapy, modern SUs could be considered as drugs/agents of choice for the treatment of diabetes.

FUNDING

Sanofi India.

Euthymia in Diabetes: Clinical Evidence and Practice-Based Opinion from an International Expert Group

AIM

To develop an evidence-based expert group opinion on various types of euthymia associated with diabetes mellitus (DM) and its management.

BACKGROUND

Diabetes mellitus is a metabolic syndrome characterized by diverse biomedical and psychosocial features. Emotional health disturbances may lead to psychological and psychiatric dysfunction and may negatively influence glycemic control. Patients with DM may experience diabetes distress (DD) associated with burden of self-care, interpersonal issues, and emotional worries regarding the ability to cope with the illness. Euthymia or a state of positive mental health and psychological well-being should be considered a key outcome of diabetes care. Therefore, to achieve optimal outcomes, the consideration and measurement of psychological and psychiatric aspects along with glycemic levels are very important. A group of multidisciplinary clinical experts came together in an international meeting held in India to develop a workable concept for euthymia in diabetes care. A multidisciplinary approach was suggested to enhance the clinical outcomes and facilitate patient-centered care. During the meeting emphasis was given to the concept of a euthymia model in diabetes care. This model focuses on enhancement of self-care skills in diabetic patients and preventative health awareness among diabetes care providers. Euthymia also encompasses patient-provider communication to aid enhancement of coping skills.

RESULTS

After due discussions and extensive deliberations, the expert group provided several recommendations on implementing the concept of euthymia in DM care.

CONCLUSIONS

Introduction of the concept of euthymia in routine clinical practice is important to improve the quality of life and coping skills in patients with DM. A timely clinical assessment of psychological and psychiatric aspects along with patient-reported outcomes of diabetes contributes to overall health and well-being of affected individuals.

FUNDING

Sanofi India.

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.