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Objective. To evaluate the effect of adding DPP4 inhibitor (DPP4-I) on glycemic variability (GV) in patients with type 2 diabetes mellitus (T2DM) treated with premixed human insulin (MHI). Methodology. We conducted a prospective study in patients with T2DM on twice-daily MHI with or without metformin therapy. Blinded continuous glucose monitoring was performed at baseline and following 6 weeks of Vildagliptin therapy. Results: Twelve patients with mean (SD) age of 55.8 (13.1) years and duration of disease of 14.0 (6.6) years were recruited. The addition of Vildagliptin significantly reduced GV indices (mmol/L): SD from 2.73 (IQR 2.12-3.66) to 2.11 (1.76-2.55), p=0.015; mean amplitude of glycemic excursions (MAGE) 6.94(2.61) to 5.72 (1.87), p=0.018 and CV 34.05 (8.76) to 28.19 (5.36), p=0.010. In addition, % time in range (3.9-10 mmol/l) improved from 61.17 (20.50) to 79.67 (15.33)%, p=0.001; % time above range reduced from 32.92 (23.99) to 18.50 (15.62)%, p=0.016; with reduction in AUC for hyperglycemia from 1.24 (1.31) to 0.47 (0.71) mmol/day, p=0.015. Hypoglycemic events were infrequent and the reduction in time below range and AUC for hypoglycemia did not reach statistical significance. Conclusion. The addition of DPP4-I to commonly prescribed twice-daily MHI in patients with T2DM improves GV and warrants further exploration.

Metformin is a biguanide oral antidiabetic agent which lowers blood glucose by decreasing hepatic gluconeogenesis. In the absence of contraindications, it is the initial treatment in most patients with type 2 diabetes along with lifestyle modifications. This drug however is commonly associated with gastrointestinal side effects especially diarrhoea which could be potentially life-threatening if prolonged. We report a case of chronic severe painless diarrhoea with weight loss over 8 months in a 40-year-old man after starting metformin for his newly diagnosed type 2 diabetes. Although the diarrhoea resolved when the patient temporarily stopped taking metformin, he decided to resume the medication to ensure his blood glucose is optimally controlled. He suspected metformin to be the cause of his diarrhoea but did not report this to his doctor during follow-up. The patient was later admitted for hypovolemic shock and severe metabolic acidosis with acute kidney injury when his diarrhoea worsened with acute gastroenteritis. He required mechanical ventilation, inotropic support and Continuous Renal Replacement Therapy in the ICU. This was further complicated by left eye ischemic optic neuropathy attributed to the acute volume loss as radiological investigations were unremarkable. Multiple laboratory and radiological investigations were done to look for the cause of the diarrhoea with no underlying pathology found. Metformin was discontinued upon admission and his diarrhoea subsequently resolved 8 days later. Upon follow-up a month later, the patient continued to be diarrhoea free without metformin. This case highlights the importance of patient education on the side effects of a medication like metformin upon commencement of the drug and to encourage the patient to notify their healthcare provider timely if they experience those side effects. This not only empowers patients to participate in their own healthcare but would avoid severe drug-related adverse events that can result in unwanted long-term sequelae. Presentation: No date and time listed

Glycemic variability (GV) is emerging as an exciting therapeutic target for diabetes mellitus (DM) with recent evidences showing association of GV with hypoglycemia risk as well as chronic complications.(1,2) Twice daily human premixed insulin is commonly used in developing countries and Asia for treatment of type 2 DM (T2DM). (3) While more convenient and cost saving, human premixed insulin regime may increase GV due to lesser flexibility and less physiological pharmacokinetic profile. Dipeptidyl peptidase IV inhibitors (DPPIV-I) have been shown to improve GV when used for treatment of T2DM but the effects of DPPIV-I when added on human premixed insulin is limited. We therefore evaluated the changes in GV following addition of DPP IV-I among T2DM patients treated with premixed human insulin with or without metformin therapy. This was a prospective study involving adult patients with T2DM on stable doses of premixed human insulin with or without metformin for at least 3 months from two state hospitals in Malaysia. Blinded continuous glucose monitoring (CGM) were performed at baseline and following 6 weeks of adding Vildagliptin to their insulin regime. A total of 12 patients were recruited (50% male). Mean (SD) age was 55.8 (13) years with mean duration of disease of 14 (6.6) years. The addition of Vildagliptin significantly reduced GV indexes including SD 2.98 (1.17) to 2.33 (0.82), p=0.017; MAGE 6.94 (2.61) to 5.72 (1.87), p=0.018; MAG 1.60 (0.76) to 1.23 (0.48), p=0.009 and M Value 13.96 (13.01) to 6.52 (7.45), p=0.037. In addition there were improvements in terms of parameters for glycemic control. Time spent in optimal glycemic range (4-8 mmol/l) improved from 38.33 (19.69) to 58.17 (5.95) %, p=0.001 with reduction in AUC for hyperglycemia from 2.09 (1.73) to 1.06 (1.09) mmol/day, p=0.010. Hypoglycemia events were infrequent and the reduction in time spent in hypoglycemia [5.92(9.74) to 1.91 (2.54)%, p=0.191] as well as AUC for hypoglycemia [0.03(0.54) to 0.01(0.02) mmol/day, p=0.163] were found although these did not reach statistical significance. We concluded that addition of DPP IV-I to commonly prescribed twice daily premixed human insulin regime in patients with T2DM may improve GV and glycemic control and warrant further exploration. References (1) Gerry Rayman. Glycaemic control, glucose variability and the triangle of diabetes care. Br J Diabetes 2016;16(Suppl1):S3-S6 (2) Boris P. Kovatchev. Metrics for glycaemic control - from HbA1c to continuous glucose monitoring. Nat Rev Endocrinol. 2017 Jul;13(7):425-436 (3) Kalra S, Balhara YP, Sahay BK, Ganapathy B, Das AK. Why is premixed insulin the preferred insulin? Novel answers to a decade-old question. J Assoc Physicians India. 2013 Jan;61(1 Suppl):9-11

The prevalence of mediastinal parathyroid adenoma is unknown. Embryological origin and more extensive aberrant migration of the parathyroid glands result in ectopic glands found in the mediastinum. We report herein 4 cases of ectopic parathyroid adenoma causing primary hyperparathyroidism from three public hospitals in MalaysiaCase 1.A 70 year old lady with underlying diabetes mellitus, hypertension, chronic immune thrombocytopenic purpura and liver cirrhosis presented with incidental asymptomatic hypercalcemia during an admission for pneumonia. Her blood results revealed high corrected calcium of 2.93 mmol/L (2.02-2.60) and a low phosphate of 0.66 (0.81-1.45) mmol/L with an unsuppressed intact parathyroid hormone (iPTH) of 14.56 pmol/L (1.6-6.9). She had an equivocal urinary calcium excretion ratio of 0.01. Her bone mineral density confirmed severe osteoporosis at distal radius and neck of femur with a Tscore of -3.6 and -3.1 respectively. A hyperfunctioning ectopic parathyroid gland was seen in the Technetium Sestamibi scan which corelates with a mediastinal lymphadenopathy on CECT. The largest node measured 1.6 x 1.2 cm. Parathyroid gland was confirmed on HPE of the video-assisted-thoracoscopic surgical (VATS) excision of the mediastinal mass. Intraoperative iPTH (ioPTH) serially reduced from 8.87 to 1.94 to 1.03 pmol/L and she maintained a serum calcium levels of 2.4 mmol/L post surgery. She did not require any calcium or vitamin D supplementation. Case 2. A 36 year old male presented with generalized body weakness secondary to hypokalemia. His calcium was 3.07 mmol/l, phosphate 0.64 mmol/l and iPTH 11.53 pmol/L. Increase Technetium uptake seen at mediastinum. Post operatively, calcium normalized and remained stable 1 year later. Case 3.47 year old female presented with acute gallstone pancreatitis complicated with a pancreatic pseudocyst. She was found to have hypercalcemia of 2.77 mmol/L, phosphate 0.70 mmol/l and iPTH 21.87 pmol/L. Sestamibi scan revealed hyperfunctiong parathyroid tissue posterior to the left thyroid lobe and in the mediastinum. She is awaiting surgery. Case 4.Another asymptomatic 47 year old male who has history of post Radioactive-iodine hypothyroidism had an incidental finding of serum calcium of 2.69-2.84 mmol/L, phosphate 0.71-0.91 mmol/L and iPTH 9.89 pmol/L with urinary calcium excretion ratio of 0.019. His Sestamibi scan showed uptake at the superior mediastinum. Ectopic parathyroid gland is rarely encountered. With the advent of Technetium-Sestamibi scintigraphy, ectopic parathyroid adenoma can be localized easily. However, surgery poses a challenge due the location of the adenoma which may occasionally be near large vascular structures in the mediastinum. The availability of intraoperative PTH aids the decision for surgical exploration and completion.

Dopamine agonist monotherapy is first line therapy in giant prolactinomas even when visual field defect is present. The costlier cabergoline is often preferred over bromocriptine due to higher efficacy and tolerability profile. Described herein combined cabergoline and bromocriptine therapy in 6 cases of giant prolactinomas. Retrospective records review of 6 patients with giant prolactinoma (3 males: M1-M3, 3 females: F1-F3) in a single tertiary centre was performed. Mean age at diagnosis: 29 years (range 17-39). Mean duration of follow up: 7 years (range 3-11). Headache and visual field defect were the presenting symptoms in all cases. Basal prolactin concentration: 100000 to 468851 mIU/L (

Introduction: The Malaysian government implemented MCO or lockdown for nearly 3 months from 18 Mar to 9 Jun 2020 in response to the Covid-19 pandemic. This restricted access to usual food, workplace, and leisure sports, and also led to reduced clinic attendance. The effects of MCO on patients with chronic lifestyle diseases like DM is unknown. Methodology: This is a cross-sectional study exploring effects of MCO on adult (>18 years) DM patients (both Type 1 and Type 2) attending endocrinologist-run DM clinics in 3 tertiary centres in Malaysia. Glycaemic and metabolic parameters were collected through medical record review while data on healthcare utilisation, dietary and lifestyle habits before MCO (17 Nov 2019 to 17 Mar 2020) and during MCO were collected by investigator-administered questionnaires during routine clinic follow-up after the MCO period (10 Jun to 30 Oct 2020). Results: From a total of 207 patients (56.5% female, 73.4% T2D and 80% on insulin) no significant difference between mean (SD) A1c [8.6(2.39) % vs 8.4(2.14) %; p=0.073] or BMI [29.2(7.57) vs 29.4(9.23)kg/m2; p=0.968] were seen before and during MCO respectively. More than 95% of the patients attended clinic before MCO and at least 20.3% saw either the DM nurse educator, DM pharmacist or dietitian. In contrast, during MCO only 31.4% of patients attended clinic and less than 10% had face-to-face consultation with the DM support team. More patients also reported missing insulin (11.6% vs 7.7%) and not checking blood glucose (17.9% vs 15.5%) during MCO. Before MCO, 61.8% of patients had home-cooked food daily. During MCO this increased to 83.1%. However, there was a trend towards unhealthy eating during MCO. Patients reported eating more frequently with those eating more than 4 meals a day nearly tripled during MCO (18.4% vs 6.8%). In addition, 22% of patients recalled consuming more confectionary; a similar percentage also reported higher consumption of processed food like dry snacks, canned food and instant noodles during MCO. Mean (SD) hours of sleep [6.8 (1.35) vs 7.2 (1.73) hours; p

A 60-year-old woman presented with an enlarging goitre associated with a 9-month history of dysphagia, hoarseness, heat intolerance, palpitations and weight loss. Physical examination revealed an enlarged right thyroid gland, 8 cm × 4 cm, soft, with no associated cervical lymphadenopathy. Her pulse rate was 90 BPM, regular. She had no eye signs, tremor or sweaty palms. Thyroid function tests showed free thyroxine (fT4) of 7.75 pmol/L (normal: 12.00–22.00 pmol/L) and TSH < 0.005 mU/L (normal: 0.27–4.20 mU/L). A repeat sample to check triiodothyronine (T3) level showed elevated free T3 level at 7.71 pmol/L (normal: 3.1–6.8 pmol/L) confirming …