An Aggressive Pituitary Tumour (APT) is defined as a tumour showing unusually rapid tumour growth with invasion into surrounding structures evidenced on imaging, or clinically relevant tumour growth despite optimal standard therapies. Almost all of APTs are macroadenomas at clinical presentation accounting for up to 15% of all pituitary neoplasms. No single marker can accurately predict the behaviour of a tumour. Ki-67 index >3%, mitotic count >2 mitoses per 10 HPF and the presence of p53 expression along with imaging showing features of invasion have been the most reliable diagnostic methods. Intrinsic characteristics of the tumour determine the rapidity of tumour growth rate of recurrence and the degree of resistance to conventional treatments. Invasiveness is a major determinant of incomplete tumour resection. APTs are resistant to current available treatment options including surgery, standard medical therapy, and radiotherapy. Multimodal approach in the management comprises re-do surgery, with medical therapy including chemotherapy and radiotherapy. Temozolomide, a chemotherapeutic agent can be used in those with documented tumour growth despite optimal standard therapy. Though medical therapy alone is not effective in controlling tumour growth in APT; it helps in controlling hormone hypersecretion to some extent. Peptide receptor radionuclide therapy (PRRT), targeted therapies and immune checkpoint inhibitors are emerging treatment modalities. Lifelong follow up is required with periodic imaging and hormonal evaluation to assess treatment response, adverse effects of medications and evolution to pituitary carcinoma. Future studies are needed to identify prognostic indicators of future aggressive behaviour of pituitary tumours and biomarkers to assess treatment response.
Background: Timely insulin initiation in long-standing type 2 diabetes (T2DM) is vital to prevent complications, yet reluctance to start it, known as psychological insulin resistance (PIR) remains common. Evidence on PIR in South Asia is limited. We aimed to determine the prevalence, determinants and latent constructs of PIR among patients with T2DM in rural Sri Lanka.Methods: A cross-sectional study was conducted among adults (aged >18 years) with T2DMattending the endocrinology clinic, District General Hospital, Hambantota. PIR and psychological status were assessed using the 20-item Insulin Treatment Appraisal Scale (ITAS) and General Health Questionnaire-12, respectively. PIR was defined as a total score greater than the sample median. Exploratory factor analysis (EFA) was performed to identify the latent constructs underlying ITAS. Associations between PIR and sociodemographic and clinical characteristics were assessed using multiple logistic regression, odds ratios with 95% confidence intervals are presented.Results: Data of 311 participants (mean age 54.7 years; SD+10.4, female 63.7%, median duration of T2DM four years; IQR3-8) were included in the analysis. Over one-third (34.4%) had only primary education, over 60% had low income (<50,000LKR/month), and 59.5% were unemployed. The prevalence of PIR was 76.8%(n=239) and psychological distress was 6.4%(n=20). EFA revealed five latent factors within PIR; loss of autonomy with insulin use (35.4%), negative impact of injecting insulin (28.7%), emotional discomfort with injecting insulin (35.9%), positive impact of insulin (38.3%), and personal failure in diabetes management (66.4%). Increasing age (OR=1.05;1.01-1.08), being insulin naïve (OR=1.99;1.11-3.97), and having middle level of family income comparted to lowest level (OR=2.64;1.12-6.17) increased the risk of PIR, while longer duration of diabetes had lower risk of PIR (OR=0.92;0.87-0.97).Conclusion: The prevalence of PIR in Sri Lankan rural settings is high, posing a substantial barrier to effective diabetes management. This resistance is particularly pronounced among those who are older, insulin-naive, and from middle-income families.
Primary aldosteronism (PA) encompasses a heterogenous group of disorders which is characterized by autonomous excessive aldosterone production resulting in low-renin hypertension. Rarely, PA might manifest as gestational hypertension for the first time because pregnancy related hormonal changes could unmask pre-existing subclinical PA. The data are sparse on prevalence, diagnosis and management of PA during pregnancy. We present a case of a 31-year-old previously normotensive woman who was diagnosed with gestational hypertension at 27th week of her second pregnancy with persistent hypokalaemia and metabolic alkalosis. She underwent emergency lower segment Caesarean section at 36th week of gestation due to inadequate control of blood pressure (BP). Her endocrine workup revealed an elevated plasma aldosterone concentration (PAC) and suppressed plasma renin concentration (PRC). The PAC to PRC ratio was markedly elevated, which is highly suggestive of primary aldosteronism and supports the diagnosis. Adrenal imaging with contrast enhanced computed tomography (CECT) revealed a right adrenal adenoma. So, at eighth week of postpartum, right side laparoscopic adrenalectomy was performed. Her potassium level normalised within a week and she became normotensive in three months. So, we suggest that PA must be considered even in gestational hypertension cases with atypical features.
Introduction: Type 2 diabetes mellitus is a highly prevalent disease which is chronic and lifelong and requires a high degree of patient compliance with regard to medication and life style changes. A good knowledge regarding these will be of value. Therefore we aimed to assess the knowledge regarding diet, physical activity and medication in patients diagnosed with type 2 diabetes mellitus attending the diabetes clinic, Teaching Hospital Peradeniya.Methods: This is a descriptive, cross sectional study, recruited 400 outpatients attending the diabetes clinic at Teaching hospital Peradeniya. The knowledge regarding diet, physical activity and medication among type 2 diabetes mellitus patients was assessed using an interviewer administered questionnaire.Results: Half the sample had a good level of knowledge regarding dietary recommendations, with younger age group (p< 0.05), females (p< 0.001) and a high level of education (p <0.005) having better knowledge. A good knowledge regarding physical activity was observed only in 20.8%, with high scores observed in males below 50 years of age with a high education level (p<0.05). 78.0% of the participants had a good knowledge about medication, with males (p< 0.01) and patients with longer disease duration had a significantly higher level of knowledge (p<0.005). Males had a slightly higher mean percentage total score (70.5188) than the females (69.8588) however the difference was not significant. Conclusion: knowledge levels are satisfactory with regard to diet and medication, however more detailed knowledge regarding recommended food groups are needed. Knowledge on physical activity is not complete and needs attention.
Introduction: Police officers face unique occupational challenges that may increase their risk of developing Type 2 Diabetes mellitus (T2DM). This study was carried out to find the prevalence of diabetes and other cardio-metabolic risk factors in this group. Methods: This was a cross‑sectional study covering 124 police officers of Batticaloa division. A pre‑tested questionnaire was used for collecting data by medical personnel. Anthropometric, biochemical measurements and definitions of risk factors were carried out using standard techniques. SPSS statistical software was used to analyze the data, and association between risk factors and diabetes was assessed using the Person chi-square test.Results: The mean age of the participants was 46.3 years (SD 9.47). The majority (87.09%) were males. The prevalence of T2DM was 22.58% and of pre-diabetes status was 24.5%. Family history of T2DM was noted in 34.7% of subjects. The prevalence of central obesity was 61.1% and of hypertension was 44.35%. According to the National Cholesterol Education Program criteria, metabolic syndrome was detected in 10.4% of the subjects in this study. T2DM was found in 53.84 % of regular smokers while only 28.78% of non-smokers had DM. The association between diabetes and pre-diabetes with other risk factors were not statistically significant.Conclusion: Limited sample size and/or genetic predominance would be a reason for the statistical discordance with the available evidence. This study highlights the increased prevalence of risk factors of T2DM and provides insights for targeted interventions within law enforcement institutions.
Introduction: Diabetes mellitus is a growing public health challenge in Southeast Asia, with rising concerns about factors influencing its management beyond conventional treatments. While sleep quality has been linked to metabolic health in various populations, its impact on glycemic control and related parameters in Sri Lankan individuals living with diabetes remain unexplored.Objective: To explore the association between sleep quality, glycemic control, and other metabolic parameters (obesity, hypertension, and diabetes-related quality of life) in patients with diabetes in Sri Lanka.Methods: A descriptive cross-sectional study was conducted among 220 adult patients with diabetes attending diabetes clinics at the National Hospital of Sri Lanka. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI), while glycemic control was measured with HbA1c levels. Metabolic parameters, including body mass index (BMI), blood pressure, and diabetes-related quality of life (DQoL), were also evaluated. Data were analyzed using descriptive statistics, correlation analysis, and linear regression.Results: The mean age of participants was 60.37±10.3 years, with 97.7% diagnosed with type 2 diabetes. The mean HbA1c was 8.3±2.2%, and 36.8% of patients reported poor sleep quality (PSQI > 5). Sleep quality showed a significant positive correlation with DQoL (r = 0.197, p = 0.003) and higher PSQI was associated with poorer glycemic control in adjusted linear regression (B = 0.09, p = 0.05). Additionally, poorer sleep quality was linked to an increased likelihood of hypertension (Exp(B) = 1.12, p = 0.033), although no significant association was found with obesity.Conclusion: The findings suggest that poor sleep quality is associated with worse glycemic control, hypertension, and lower quality of life in Sri Lankan diabetes patients. These results emphasize the need to consider sleep quality as an integral part of diabetes management. Further studies are needed to examine causal links and explore the potential benefits of sleep interventions in this population.
Introduction: Atypical Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital disorder characterized by agenesis or aplasia of the uterus and upper part of the vagina in a female with a normal female karyotype (46, XX) with associated extra-genital anomalies such as renal, skeletal, auditory and cardiac malformations. Sporadic cases are common but there is growing evidence of familial cases. We report two cases of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome in siblings from the same family, with their father exhibiting unilateral renal hypoplasia.Case Description: A 19-year-old female presented with the complaint of primary amenorrhea. She had undergone patent ductus arteriosus device closure at the age of 6 years. There were no features of hyperandrogenism. Her family history revealed that her father had left renal hypoplasia. On examination she had short stature and scoliosis. She had tanner 5 breast development and pubic hair distribution. She had normal female karyotyping (46 XX) and hormonal profile was within normal range with no abnormalities. Her MRI abdomen and pelvis showed an absent uterus and upper ⅔ of the vagina, single pelvic kidney with normal ovaries. Her younger sister who was 16 years old was also investigated for primary amenorrhea. She was also short and had Tanner stage 5 breast development and normal pubic hair distribution. Her hormonal profile was normal, but pelvic ultrasound revealed bilateral pelvic kidneys, an absent uterus, and bilateral ovaries located in the left and right iliac fossae, suggesting the possibility of MRKH in the sibling as well. Discussion & conclusion: MRKH syndrome is the second commonest cause for primary amenorrhea where the aetiology remains controversial. Majority of the cases are sporadic but there is emerging evidence of familial cases of MRKH suggesting a genetic etiology. During the last decade, there has been advancement in the genetic studies related to MRKH syndrome. Understanding the genetics related to MRKH syndrome is of great importance to provide genetic counselling in the clinical setting.
Introduction: Previous studies have indicated that diabetes mellitus was less prevalent in rural regions compared to metropolitan areas. However, recent data revealed significant increases in the prevalence of diabetes mellitus in rural areas as well. This study aimed to describe prevalence of diabetes and hypertension among adults attending health screening programmes at Rural Health Research Centre in Kataragama.Methods: A cross-sectional study was conducted in conjunction with health screening programmes on World Diabetes Day and World Hypertension Day in 2023 at the Rural Health Research Centre in Kataragama. Adult residents (aged >18 years) of the Kataragama Medical Officer of Health area were invited to participate in these health screenings. Medical officers evaluated all participants for diabetes and hypertension. Anthropometric measurements and blood pressure assessments were conducted, and blood samples were collected for fasting plasma glucose (FPG) and serum Creatinine tests. Diabetes diagnoses were made according to the latest guidelines from the American Diabetes Association, while hypertension was assessed following the criteria set by the American Heart Association. Categorical associations were analyzed using the Chi-square test with SPSS software.Results: A total of 170 individuals (mean age of 49.3(±13.2), females -70.1%) participated in the clinics. Mean FPG was 110.4 mg/dl (±24.2), BMI was 26.02 kg/m2 (± 5.6) and serum creatinine value 0.83mg/dl(±0.3). The prevalence were as follows: overweight - 45.5%, obesity - 31.7%, diabetes - 17.9%, pre-diabetes - 29.3%, elevated hypertension-18.6%, stage I hypertension-31.1% and stage II hypertension-14.4%. Significant association was found between hypertension stages and advancing age groups (p=0.038) and with sex categories (p=0.036). Among the overweight participants, 11.1% were in stage I and 25% in stage II hypertension, while 29.0% and 23.7% of obese groups had hypertension I and II respectively.Conclusion: Prevalence of diabetes and hypertension were high in this rural community. Health promotional camps can be effectively used to detect the undiagnosed cases.
Introduction: Globally, there is a rising trend in young-onset diabetes (YOD) prevalence, with type 1 diabetes (T1DM) contributing to the majority. However, in recent years, type 2 diabetes (T2DM) has had a notable impact on YOD prevalence. Diabetes is considered a cardiovascular disease equivalent. This is further compounded by obesity-associated insulin resistance (IR). With the increasing prevalence of YOD and longer life expectancy, assessing and addressing cardiovascular disease (CVD) risk in this population has gained importance. In this study, we aimed to determine the presence of CVD risk factors in a YOD population.Methods: A descriptive, cross-sectional study was carried out among people with YOD attending a specialised clinic in a tertiary care centre. Traditional CVD risk factors, including anthropometric measures and exercise and dietary habits, were assessed. Data analysis was done using SPSS.Results: The study included 95 participants, 54.7% (n=52) females, with a mean age of 23.8 ± 6.2 years and an average diabetes duration of 7.0 ± 5.9 years. Among the participants, 63% had T1DM, and 24% had T2DM. The mean age of disease onset was 17.0 ± 4.5 years. The prevalence of microvascular complications was as follows: retinopathy 12.7% (n=12), nephropathy 5.3% (n=5), and neuropathy 4.7% (n=4). One patient(1%) had ischemic heart disease. The population’s mean BMI was 21.59± 4.58 kg/m², with 12%(n=11) overweight and 25%(n=24)obese participants. In the population, 34% (n=32)) had dyslipidemia, 10%(n=9) had hypertension, and 7%(n=6) were smokers.A total of 78% (n=18) of T2DM patients and 16.7% (n=10) of T1DM patients were classified as either overweight or obese. Both males and females with T2DM had higher waist circumference (WC) and waist-to-height ratios (WHR) compared to their specific gender with T1D (p<0.05). Among T1DM patients, females had higher WC and WHR than males. However, only female T2DM patients exceeded the safe thresholds for WC and WHR. Per centage, prevalence of anthropometric risk factors,high LDL and Low HDL were highest in females with T2DM; the average daily intake of carbohydrates was 214g. The contribution of carbohydrates to the daily macronutrient content in the diet was 62% in T1DM and 76% in T2DM. Despite 71% of the population consuming vegetables daily, only a quarter of the participants consumed fruit. None of the study participants met the daily recommended physical activity levels.Conclusion: While the prevalence of anthropometric risk factors for cardiovascular disease is higher in T2DM patients, it is also prevalent in a significant proportion of T1DM patients, with a female predominance in both groups. Additionally, the study's findings underscore the importance of addressing lifestyle factors like diet and exercise and optimising cardiovascular risk reduction strategies in YOD populations to tackle the CVD risk regardless of the type of diabetes.
Introduction: Neuroendocrine neoplasms (NENs) are a heterogeneous group of tumors arising from neuroendocrine cells, with increasing incidence worldwide. Limited data exist on NENs in Sri Lanka. This study describes the demographic, anatomical, and pathological characteristics of NENs in Sri Lanka and compares findings with regional and global data.Methods: A retrospective descriptive study was conducted using histopathology reports from seven centers in Sri Lanka from January 2017 to June 2021. A total of 151 patient records were analyzed, categorized based on the 2022 WHO classification for NENs.Results: The sample included 77 males and 74 females, with a median age of 58 years. Primary NENs accounted for 71% of cases, with gastroenteropancreatic NENs (GEP-NENs) being the most common (75.7%). Pancreatic NENs were the most frequent (41.9%), followed by small intestinal NENs (30.9%). The liver was the most common metastatic site (36%). Immunohistochemical markers chromogranin A and synaptophysin were positive in 82.8% and 79.5% of cases, respectively. Well-differentiated tumors (Grade 1 and 2) comprised 65%, while neuroendocrine carcinomas (NECs) accounted for 35%.Discussion: The pathological characteristics of NENs in Sri Lanka align with global and regional data, with pancreatic and small intestinal NENs being the most common. However, regional variations emphasize the need for localized studies and tailored management approaches.Conclusion: This study enhances understanding of NENs in Sri Lanka, highlighting the need for improved diagnostic expertise, systematic data collection, and further research to improve patient outcomes.
Background: Distal symmetric polyneuropathy (DSPN) is the commonest type of neuropathy among people living with diabetes. We aimed to describe the clinical manifestations, foot complications, quality of life and self-care practices among adults with diabetic DSPN.Methods: We conducted a cross-sectional study in the Diabetes Clinic of National Hospital Colombo, Sri Lanka in 2022. Adults with diabetes and symptoms and/or signs of DSPN were recruited by consecutive sampling at Annual Diabetes End-organ Screening. Demographic and clinical data were collected via patient interviews and review of medical records. Quality of life (QoL) was determined using the SF-36 questionnaire.Results: Among 201 patients with diabetic DSPN (mean age 61 years [SD 10], men 39%, median duration of diabetes 15 years [IQR 8-25], loss of protective sensation in 99%), 65% had one or more DSPN-related foot complications (deformity 12%, pre-ulcer 59%, past or present ulcer 13%, lower limb amputation 5%). Peripheral arterial disease (B=1.88, SE=0.67, p=0.005) and body mass index (B=0.1, SE=0.05, p=0,027) were independent predictors DSPN-related foot complications. 129 (64%) reported burning pain in feet. Among them, only 27% received pharmacological treatment and amongst those treated, only 24% achieved symptom relief. QoL scores were lowest in physical function (45 [IQR 30-80]) and bodily pain (63 [IQR 45-78]) domains and scores were lower among those with burning pain, compared to those without. Self-care practices were suboptimal (daily foot inspection 78%, footwear both indoors and outdoors 36%, use of diabetic footwear 7%).Conclusion: Among Sri Lankan adults living with diabetes and DSPN, 65% had one or more foot complications while 64% had burning pain in feet, which was not treated or inadequately treated in the majority. DSPN was associated with reduced QoL score. Foot-related self-care practices remain suboptimal even amongst those with DSPN and foot complications.
This article presents a comprehensive exploration of a complex case of Cushing's syndrome in a 29-year-old woman, characterized by significant weight gain, diabetes, and hypertension. The diagnostic journey involves meticulous examination, radiological imaging revealing an adrenal adenoma, and an unexpected twist in the immunohistochemical analysis - diffuse ACTH positivity despite suppressed plasma ACTH levels. This finding challenges conventional understanding and raises questions about paracrine influences. The patient's postoperative course is marked by undetectable serum cortisol levels, indicating successful surgical intervention, yet an unforeseen challenge emerges—prolonged suppression of the hypothalamo-pituitary-adrenal axis. This persistent adrenal axis suppression, even at two years postoperatively, presents a noteworthy and intricate aspect of the case. Through this case study, we aim to contribute valuable insights into the complexities of Cushing's syndrome, emphasizing the importance of recognizing atypical presentations, understanding histological nuances, and addressing the prolonged consequences of adrenal axis suppression.
