Use of hypertonic saline in severe symptomatic hyponatraemia; results from a national survey of endocrinologists in the United Kingdom.

BACKGROUND: Severe symptomatic hyponatraemia is potentially life-threatening and hypertonic saline (HTS) is effective at rapidly correcting serum sodium. Several clinical guidelines have aimed to standardise the administration of HTS. However, evidence supporting the guidelines is limited, and concerns have been raised regarding the potential for overcorrection. OBJECTIVE: To assess the practices and perceptions surrounding HTS use in severe symptomatic hyponatraemia among United Kingdom (UK) endocrinologists and trainees. METHODS: An anonymous online survey was disseminated to Society for Endocrinology (UK) clinical members between 24/10/2023 and 30/11/2023 using a web-based multiple-choice questionnaire. RESULTS: We received 133 responses with a survey response rate of 8.3% (60.1% consultants, 33.1% trainees, 6.8% others). 85% of respondents employed bolus treatment with HTS only, with 9.8% using both bolus and continuous infusions. Most (53.2%) preferred 150 mL boluses, followed by 100 mL boluses (19.8%), while 5.5% of respondents used weight-based dosage. Commonly used HTS strengths were 2.7% (45.1%), followed by 1.8% (31.6%), while the 3% HTS strength recommended in guidelines was used by 21.8%. Contrary to guidelines, 78.6% did not administer a second bolus without waiting for the sodium result after the first bolus. Moreover, 86% have experience using venous blood gas sodium readings for monitoring. Overcorrection targets defined by 10 and 8 mmol/24 h cut-offs were used by 48.9% and 39.9%, respectively. For definite or anticipated overcorrection, 75.9% preferred 5% dextrose, while 40.6% had experience with desmopressin. CONCLUSION: Significant variation exists in HTS use for severe symptomatic hyponatraemia in the UK. Most clinicians prefer a more cautious approach in administering HTS. These data offer insight into real-life care and call for future research.

Diabetic autonomic neuropathy does not impede improvement in hypoglycaemia awareness in adults: Sub-study results from the HypoCOMPaSS trial.

AIMS: Impaired awareness of hypoglycaemia (IAH) increases the risk of severe hypoglycaemia in people with type 1 diabetes mellitus (T1DM). IAH can be reversed through meticulous avoidance of hypoglycaemia. Diabetic autonomic neuropathy (DAN) has been proposed as an underlying mechanism contributing to IAH; however, data are inconsistent. The aim of this study was to examine the effects of cardiac autonomic neuropathy (CAN) on IAH reversibility inT1DM. METHODS: Participants with T1DM and IAH (Gold score ≥4) recruited to the HypoCOMPaSS (24-week 2 × 2 factorial randomised controlled) trial were included. All underwent screening for cardiac autonomic function testing at baseline and received comparable education and support aimed at avoiding hypoglycaemia and improving hypoglycaemia awareness. Definite CAN was defined as the presence of ≥2 abnormal cardiac reflex tests. Participants were grouped according to their CAN status, and changes in Gold score were compared. RESULTS: Eighty-three participants (52 women [62.7%]) were included with mean age (SD) of 48 (12) years and mean HbA1c of 66 (13) mmol/mol (8.2 [3.3] %). The mean duration of T1DM was 29 (13) years. The prevalence of CAN was low with 5/83 (6%) participants having definite autonomic neuropathy with 11 (13%) classified with possible/early neuropathy. All participants, regardless of the autonomic function status, showed a mean improvement in Gold score of ≥1 (mean improvement -1.2 [95% CI -0.8, -1.6]; p < 0.001). CONCLUSIONS: IAH can be improved in people with T1DM, and a long duration of disease, with and without cardiac autonomic dysfunction. These data suggest that CAN is not a prime driver for modulating IAH reversibility.

A retrospective study on weaning glucocorticoids and recovery of the hypothalamic-pituitary-adrenal axis.

CONTEXT: Glucocorticoids suppress the hypothalamic-pituitary-adrenal (HPA) axis resulting in tertiary adrenal insufficiency (AI). When weaning patients off glucocorticoids there is no consensus on whether to maintain patients on prednisolone or convert to hydrocortisone. OBJECTIVE: Investigate HPA axis recovery in patients on long-term prednisolone and assess outcome after hydrocortisone conversion. DESIGN: Retrospective cohort study. SETTING: Outpatient endocrine steroid clinic. PATIENTS: Patients on long-term prednisolone referred for HPA axis testing between 2015-2022. MAIN OUTCOMES MEASURED: 1) HPA axis recovery rate in patients on prednisolone demonstrated by normal ACTH stimulation test (AST).2) HPA axis recovery rate sub-analysis of dose-matched patients with confirmed tertiary AI on prednisolone or hydrocortisone. RESULTS: 206 patients on prednisolone were tested for tertiary AI. Of these 176 remained on prednisolone while 30 were converted to hydrocortisone. The overall HPA axis recovery rate for patients on prednisolone after interval testing was 137/206 (66.5%). HPA axis recovery rate in dose-matched prednisolone and hydrocortisone conversion groups was 7/10 (70%) and 2/13 (15%) (p=0.008), respectively. There was no difference in mean (SD) age (67.1(12.2) v 63.4(11.1) years; p=0.464) and baseline cortisol (5.3(4.2) v 4.6(3.1)µg/dL; p=0.648) and median [IQR] glucocorticoids duration (1213[1114] v 2316[4808] days; p=0.693) and baseline ACTH (20.5[29.0] v 16.3[14.8]ng/L; p=0.905) between dose-matched prednisolone and hydrocortisone groups. Follow-up duration in prednisolone group was significantly lower (median [IQR] 348[975] v 667[884] days; p=0.012). CONCLUSIONS: Patients with glucocorticoid induced AI maintained on once-daily prednisolone can recover HPA axis function when weaning. There is no apparent advantage to recover HPA axis function in converting to multiple dosing hydrocortisone.

Multivariable Model to Predict an ACTH Stimulation Test to Diagnose Adrenal Insufficiency Using Previous Test Results.

Context: The adrenocorticotropin hormone stimulation test (AST) is used to diagnose adrenal insufficiency, and is often repeated in patients when monitoring recovery of the hypothalamo-pituitary-adrenal axis. Objective: To develop and validate a prediction model that uses previous AST results with new baseline cortisol to predict the result of a new AST. Methods: This was a retrospective, longitudinal cohort study in patients who had undergone at least 2 ASTs, using polynomial regression with backwards variable selection, at a Tertiary UK adult endocrinology center. Model was developed from 258 paired ASTs over 5 years in 175 adults (mean age 52.4 years, SD 16.4), then validated on data from 111 patients over 1 year (51.8, 17.5) from the same center, data collected after model development. Candidate prediction variables included previous test baseline adrenocorticotropin hormone (ACTH), previous test baseline and 30-minute cortisol, days between tests, and new baseline ACTH and cortisol used with calculated cortisol/ACTH ratios to assess 8 candidate predictors. The main outcome measure was a new test cortisol measured 30 minutes after Synacthen administration. Results: Using 258 sequential ASTs from 175 patients for model development and 111 patient tests for model validation, previous baseline cortisol, previous 30-minute cortisol and new baseline cortisol were superior at predicting new 30-minute cortisol (R2 = 0.71 [0.49-0.93], area under the curve [AUC] = 0.97 [0.94-1.0]) than new baseline cortisol alone (R2 = 0.53 [0.22-0.84], AUC = 0.88 [0.81-0.95]). Conclusion: Results of a previous AST can be objectively combined with new early-morning cortisol to predict the results of a new AST better than new early-morning cortisol alone. An online calculator is available at https://endocrinology.shinyapps.io/sheffield_sst_calculator/ for external validation.

Abnormal Calcium Levels are Associated With Worse Maternal and Fetal Outcomes; Results From an Exploratory Study.

CONTEXT: Precise estimates of the incidence of hyper- and hypocalcemia in pregnancy are unknown. Abnormal calcium levels have been associated with unfavorable pregnancy-related outcomes. OBJECTIVE: Determine frequency of hypercalcemia and hypocalcemia in pregnancy when tested and their associations with maternal and fetal outcomes. DESIGN: Exploratory retrospective cohort study. SETTING: Single tertiary care maternity unit. PATIENTS: Pregnant women with expected delivery date between 2017 and 2019 and a second additional cohort of pregnant women with hypercalcemia between 2014 and 2016 and 2020 and 2021. INTERVENTIONS: Observational. MAIN OUTCOMES MEASURED: (1) Incidence of hyper- and hypocalcemia when calcium tested; (2) maternal outcomes: incidence of preterm delivery, emergency cesarean section, and blood loss during delivery; and (3) fetal outcomes: fetal loss (miscarriage/stillbirth), neonatal intensive care unit admission, and fetal birth weight (for term deliveries). RESULTS: Total number of gestations and livebirths recorded were 33 118 and 20 969, respectively, with median [interquartile range] age of 30.1 [25.6-34.3] years. A total of 15.7% (n = 5197) of all gestations had albumin-adjusted calcium tested, and incidence of hypercalcemia and hypocalcemia when tested was 0.8% (n = 42) and 9.5% (n = 495), respectively. Both hypercalcemia (including additional cohort n = 89) and hypocalcemia were associated with increased incidence of preterm delivery (P < .001), emergency cesarean section (P < .001 and .019), blood loss (P < .001), and neonatal intensive care unit admission (P < .001). A total of 27% in the hypercalcemic group had an established diagnosis of primary hyperparathyroidism. CONCLUSIONS: Abnormal calcium levels during pregnancy are common and associated with worse pregnancy-related outcomes, which raises the possible need for routine calcium testing. Prospective studies to confirm the incidence, etiology, and effects of abnormal calcium in pregnancy are recommended.

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.

Hypertonic saline for severe symptomatic hyponatraemia: real-world findings from the UK.

Objective: To evaluate 'real-world' safety and efficacy of the European Society of Endocrinology guidelines for the treatment of severe symptomatic hyponatraemia using hypertonic saline (HTS). Design: Retrospective, observational, cohort study, examining the use of HTS for severe symptomatic hyponatraemia at Sheffield Teaching Hospitals between 2017 and 2020. Methods: Patients were identified from pharmacy records and demographic, clinical, and treatment data extracted. Results: Out of 112 patients (females:males = 61:51), the mean age ± s.d. was 66.3± 16.0 years and mean pre-treatment serum sodium ± s.d. was 113.8 ± 6.4 mmol/L. Overall, overcorrection rates at 24 and 48 h (>10 and >18 mmol/L) were 44.9 and 19.6%, respectively, while 19.6% of patients were treated for overcorrection. Above-target rise in sodium (>5 mmol/L) after first and second boluses was noted in 22.6 and 34.6% of patients, respectively. In-hospital and 12-month mortality was 7.1 and 18.7%, respectively, with no cases of osmotic demyelination. The mean venous blood gas (VBG) sodium was 1.9 mmol/L lower than paired serum sodium (n = 36) (113.6 ± 6.6 vs 115.7 ± 7.8 mmol/L). Conclusion: We report real-world data demonstrating that a significant number of patients overcorrected using current guidelines. Also, several patients had above-target rise in sodium after one bolus of HTS, and sodium measurement should be considered before the second bolus unless ongoing severe symptoms persist. A point of care VBG sodium concentration was useful for this purpose. In addition to careful monitoring, a cautious but anticipatory overcorrection prevention strategy should be considered in the first 24 h.

Parathyroid hormone of ≥1.6 pmol/L at 6 months is associated with recovery in 'long-term' post-surgical hypoparathyroidism.

Objective: Post-surgical hypoparathyroidism (PoSH) usually settles within few months after thyroid surgery, but several patients require long-term supplementation with calcium/activated vitamin D. When PoSH persists beyond 6 months, it is considered 'chronic' or 'permanent', however, late recovery has been reported. The aim of this study was to determine the frequency of late recovery and explore factors predicting late recovery of parathyroid function. Methods: Adult patients undergoing total/completion thyroidectomy between 2009 and 2018 were included in this retrospective cohort observational study. The records of patients with evidence of PoSH were reviewed to identify those with persisting PoSH at 6 months. Demographic, biochemical, surgical, pathological, and clinical follow-up data were collected and analysed. Results: Out of 911 patients undergoing thyroidectomy, 270 were identified with PoSH. Of these, 192 were started on supplements and 138 (71.9%) recovered within 6 months. Of the remaining 54 patients, 35 had ongoing PoSH with median (range) follow-up of 3.4 (0.5-11.1) years. Nineteen patients were weaned off supplements and achieved remission at median (range) follow-up of 1.3 (0.6-4.8) years. All of those who recovered had a PTH of ≥1.6 pmol/L at 6 months. There was no difference in age, gender, diagnosis, type, and extent of surgery between those who did and did not show late recovery. Conclusions: Recovery from PoSH is common beyond 6 months, raising the question whether a 6-month threshold to define 'long-term' PoSH is appropriate. The chances of recovery are high (~50%) in patients with PTH level ≥1.6 pmol/L at 6 months, where attempts at weaning may be focussed.

Ab Initio Calculation of Surface Thermochemistry for Popular Solid Transition Metal-Based Species.

This work reports the thermochemistry calculations for solid-phase periodic models of ten popular transition metal-based species. These model structures were refined to stable geometry by geometric optimization along with calculating the thermodynamic properties including enthalpy, entropy, heat capacity at constant pressure, and Gibbs free energy by DMol3 package via first-principles ab initio calculations. The temperature-dependent thermochemistry values were converted to a NASA seven-polynomial format. The behavior of different thermodynamic parameters based on temperature was investigated and their comparative analysis was done. A higher number of atoms tends to show higher thermodynamic values. Moreover, these thermodynamic values agree reasonably well with previously reported experimental and computational values. Metal copper shows higher thermodynamic values as compared to its oxide. The thermodynamic properties of lanthanum-based oxides have been newly calculated through the ab initio method. Amorphous structures reveal higher thermodynamic values compared to their crystalline counterparts. A comparison between different transition metal-based species gives a better understanding of the different crystalline structures and their surface sites. These calculated thermodynamic data and polynomials can be used for a variety of thermodynamic calculations and kinetic modeling.

Higher admission activated partial thromboplastin time, neutrophil-lymphocyte ratio, serum sodium, and anticoagulant use predict in-hospital COVID-19 mortality in people with Diabetes: Findings from Two University Hospitals in the U.K.

AIMS: To create and compare survival models from admission laboratory indices in people hospitalized with coronavirus disease 2019 (COVID-19) with and without diabetes. METHODS: Retrospective observational study of patients with COVID-19 with or without diabetes admitted to Sheffield Teaching Hospitals from 29 February to 01 May 2020. Predictive variables for in-hospital mortality from COVID-19 were explored using Cox proportional hazard models. RESULTS: Out of 505 patients, 156 (30.8%) had diabetes mellitus (DM) of which 143 (91.7%) had type 2 diabetes. There were significantly higher in-hospital COVID-19 deaths in those with DM [DM COVID-19 deaths 54 (34.6%) vs. non-DM COVID-19 deaths 88 (25.2%): P < 0.05]. Activated partial thromboplastin time (APPT) > 24 s without anticoagulants (HR 6.38, 95% CI: 1.07-37.87: P = 0.04), APTT > 24 s with anticoagulants (HR 24.01, 95% CI: 3.63-159.01: P < 0.001), neutrophil-lymphocyte ratio > 8 (HR 6.18, 95% CI: 2.36-16.16: P < 0.001), and sodium > 136 mmol/L (HR 3.27, 95% CI: 1.12-9.56: P = 0.03) at admission, were only associated with in-hospital COVID-19 mortality for those with diabetes. CONCLUSIONS: At admission, elevated APTT with or without anticoagulants, neutrophil-lymphocyte ratio and serum sodium are unique factors that predict in-hospital COVID-19 mortality in patients with diabetes compared to those without. This novel finding may lead to research into haematological and biochemical mechanisms to understand why those with diabetes are more susceptible to poor outcomes when infected with Covid-19, and contribute to identification of those most at risk when admitted to hospital.

Surgically treated acromegaly patients have a similar quality of life whether controlled by surgery or requiring additional medical therapy (QuaLAT Study).

PURPOSE: There is no consensus on quality of life (QOL) in patients with acromegaly requiring medical treatment after surgery compared with those achieving remission by surgery alone. METHODS: QuaLAT is a cross-sectional study comparing QOL in surgery-only treated acromegaly patients versus those requiring medical treatment post-surgery. Patients attending clinics were identified and divided into-Group 1: patients who had surgery only and were in biochemical remission, Group 2: all patients on medical treatment post-surgery, Group 3: patients from Group 2 with biochemical control. Participants were asked to fill three questionnaires; Acromegaly Quality of Life Questionnaire (ACROQOL), 36-Item Short Form Survey (SF36), and Fatigue Severity Scale (FSS). RESULTS: There were 32 patients in Group 1 and 25 in Group 2. There was no difference in QOL scores between groups 1 and 2, as measured by ACROQOL (mean difference [MD] = - 2.5, 95% CI - 16.6 to 11.6; p = 0.72), SF36v2 [Physical component score (PCS) MD = - 4.9, 95% CI - 10.9 to 1.2; p = 0.12; mental component score MD = - 3.0, 95% CI - 10.5 to 4.4; p = 0.44], or FSS (MD = - 0.004, 95% CI - 1.14 to 1.33; p = 0.1). Comparison between groups 1 and 3 however showed that PCS (and 3 subdomains) was significantly better in group 3 (MD = - 8.3, 95% CI - 14.8 to -1.8; p = 0.01). All three QOL scores were lower when compared with healthy controls. CONCLUSIONS: Medical treatment not only achieves a QOL comparable to surgery, it may also be associated with better QOL in physical subdomains. When compared with healthy controls, QOL remains worse in treated acromegaly patients compared to controls.

Severe Hypothyroidism Presenting With Rhabdomyolysis in a Young Patient.

Rhabdomyolysis is an uncommon but potentially life-threatening medical condition. The acute muscle breakdown leads to the release of toxic muscle contents which can damage the kidneys and can cause the development of acute kidney injury (AKI) and fatal electrolyte imbalances associated with high morbidity and mortality. There are a variety of causes including exposure to extremely hot weather, toxins, trauma, certain drugs, and rarely endocrine disorders in particular thyroid dysfunction. It is more common among a certain group of people, for example, enthusiastic athletes, physical laborers, military and police personnel working in hot and humid weather. Moreover, it is also seen in patients using certain medications, and in the elderly following a fall and prolonged laying on the floor. The majority of the patients develop acute kidney failure and treatment with intravenous hydration and the underlying cause remains the mainstay of management. Our case demonstrates the rare occurrence of AKI induced by rhabdomyolysis in patients with severe hypothyroidism. A 36-years-old male presented with generalized body pains, arthralgias, weight gain, and ankle edema of three months duration. On investigations, he was found to have severe hypothyroidism, AKI along with raised creatinine kinase (CK) and myoglobin indicating severe muscle damage. He was treated with intravenous (IV) fluids and oral levothyroxine in accordance with endocrine team advice. This case highlights the significance of investigating acute rhabdomyolysis with thyroid function tests if no other cause is apparent from history like hyperthermia/drugs/toxins as in our case. Timely diagnosis and treatment of underlying pathology improve patient outcomes.

Current and future treatment options for adrenal insufficiency.

PURPOSE OF REVIEW: Patients with adrenal insufficiency (AI) irrespective of being on glucocorticoid replacement therapy still suffer from increased morbidity and mortality. A major contributing factor is an inability of conventional glucocorticoid treatment to mirror the physiological cortisol rhythm. Novel strategies to replicate the cortisol rhythm using hydrocortisone infusion pumps and oral modified release hydrocortisone have now been developed and confirmed to offer benefits to patients. RECENT FINDINGS: In the DREAM study, when compared to multiple daily dosing of glucocorticoids Plenadren reduced weight, was less immunosuppressive and resulted in a better quality of life besides reducing infections. Chronocort that provides the early morning rise in cortisol improves androgen concentrations compared to conventional glucocorticoid treatments in congenital adrenal hyperplasia (CAH). Physiological hydrocortisone infusion pumps improve cortisol profiles with better adrenocorticotrophic hormone, glucose control, and quality of life (QOL) with androgen levels better controlled in CAH. SUMMARY: Advances in glucocorticoid replacement for patients with AI are ongoing. Novel approaches to managing AI, enabled by this armamentarium of drug formulations, aims to improve patient health. Currently, their use should be reserved for patients with metabolic complications, very poor QOL and difficult-to-treat CAH. Larger studies based on outcomes are essential to understand to what extent these strategies can replace conventional treatments.

Urinary calcium indices in primary hyperparathyroidism (PHPT) and familial hypocalciuric hypercalcaemia (FHH): which test performs best?

AIM: Primary hyperparathyroidism (PHPT) is much more common than familial hypocalciuric hypercalcaemia (FHH), but there is considerable overlap in biochemical features. Urine calcium indices help with the differential diagnosis, but their reliability in making this distinction is not clear. The aim of this study was to compare urinary calcium values in patients with PHPT and FHH. METHODS: This was a case-control study of patients with PHPT who had successful surgery and genetically proven FHH between 2011 and 2016. Due to low FHH numbers, patients from neighbouring hospitals and outside study period (2017-2019) were allowed to improve power. Data on demographics and urinary calcium were obtained from electronic records and compared between the two groups. RESULTS: During the study period, 250 patients underwent successful PHPT surgery, while in the FHH arm, 19 genetically proven cases were included. The median (IQR) 24-hour urine calcium excretion (UCE) in the PHPT group was 8.3 (5.6-11.2) mmol/24 hours compared with 3.2 (2.1-6.1) mmol/24 hour in the FHH group (p<0.001). Median (IQR) calcium to creatinine clearance ratio (CCCR) in the PHPT and FHH groups was 0.020 (0.013-0.026) and 0.01 (0.002-0.02), respectively (p=0.001). The sensitivity of urinary tests for PHPT was 96% for UCE (cut-off ≥2.5 mmol/24 hour) and 47% for CCCR (cut-off >0.02). The specificity of the urinary tests for FHH was 29.4% for UCE (cut-off <2.5 mmol/24 hour) and 93% for CCCR (cut-off <0.02). CONCLUSIONS: 24-hour UCE is more sensitive in diagnosing PHPT; however, it is less specific in ruling out FHH as compared with CCCR, when the cut-offs suggested by the International guidelines from the fourth international workshop are used. A significant proportion of patients with PHPT would have also required genetic studies if the guidelines were followed.

Two Years Remission of Type 2 Diabetes Mellitus after Bariatric Surgery.

OBJECTIVE: To determine the influence of bariatric surgery on remission of type 2 diabetes mellitus (T2DM) in obese patients along with improvements in other obesity-associated comorbidities. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Doncaster and Bassetlaw NHS Trust, UK, from August 2010 to August 2018. METHODOLOGY: All the cases of bariatric surgery in obese patients with T2DM who had completed 2 years of follow up were included in the study. Remission of T2DM was defined as glycated hemoglobin (HbA1C) <48 mmol/mol (<6.5%) or fasting blood sugar of <7.0 mmol/L, not on hypoglycemic agents 2 years after having bariatric surgery. Student's t-test was used to see any difference in baseline HbA1C, BMI, percentage of weight loss, and duration of diabetes between remitters and non-remitters. RESULTS: Two years follow-up data after bariatric surgery for remission of T2DM or otherwise was available for (n=121) patients. Majority (70.2%, n=85) were females and (29.8%, n=36) were males. Mean age was 48.21 ±9.77 years. Eightythree (68.6%) patients achieved remission of T2DM at 2 years and 31.4% (n=38) did not. Remission of other comorbidities was 33.3% (n=53 out of 159) for hypertension (HTN), 50.8% (n=60 out of 118) for dyslipidemia, 67.2% (n=43 out of 64) for obstructive sleep apnea (OSA), 52.1% (n=37 out of 71) for gastro esophageal reflux disease (GERD), 25.7% (n=18 out of 70) for asthma, and 23.3% (n=24 out of 103) for depression. CONCLUSION: Bariatric surgery effectively achieves remission of T2DM and other obesity associated comorbidities.

Two cases of spontaneous remission of primary hyperparathyroidism due to auto-infarction: different management and their outcomes.

Spontaneous remission of primary hyperparathyroidism (PHPT) due to necrosis and haemorrhage of parathyroid adenoma, the so-called 'parathyroid auto-infarction' is a very rare, but previously described phenomenon. Patients usually undergo parathyroidectomy or remain under close clinical and biochemical surveillance. We report two cases of parathyroid auto-infarction diagnosed in the same tertiary centre; one managed surgically and the other conservatively up to the present time. Case #1 was a 51-year old man with PHPT (adjusted (adj.) calcium: 3.11 mmol/L (reference range (RR): 2.20-2.60 mmol/L), parathyroid hormone (PTH) 26.9 pmol/L (RR: 1.6-6.9 pmol/L) and urine calcium excretion consistent with PHPT) referred for parathyroidectomy. Repeat biochemistry 4 weeks later at the surgical clinic showed normal adj. calcium (2.43 mmol/L) and reduced PTH. Serial ultrasound imaging demonstrated reduction in size of the parathyroid lesion from 33 to 17 mm. Twenty months later, following recurrence of hypercalcaemia, he underwent neck exploration and resection of an enlarged right inferior parathyroid gland. Histology revealed increased fibrosis and haemosiderin deposits in the parathyroid lesion in keeping with auto-infarction. Case #2 was a 54-year-old lady admitted with severe hypercalcaemia (adj. calcium: 4.58 mmol/L, PTH 51.6 pmol/L (RR: 1.6-6.9 pmol/L)) and severe vitamin D deficiency. She was treated with intravenous fluids and pamidronate and 8 days later developed symptomatic hypocalcaemia (1.88 mmol/L) with dramatic decrease of PTH (17.6 pmol/L). MRI of the neck showed a 44 mm large cystic parathyroid lesion. To date, (18 months later), she has remained normocalcaemic. Learning points: Primary hyperparathyroidism (PHPT) is characterised by excess parathyroid hormone (PTH) secretion arising mostly from one or more autonomously functioning parathyroid adenomas (up to 85%), diffuse parathyroid hyperplasia (<15%) and in 1-2% of cases from parathyroid carcinoma. PHPT and hypercalcaemia of malignancy, account for the majority of clinical presentations of hypercalcaemia. Spontaneous remission of PHPT due to necrosis, haemorrhage and infarction of parathyroid adenoma, the so-called 'parathyroid auto-infarction', 'auto-parathyroidectomy' or 'parathyroid apoplexy' is a very rare in clinical practice but has been previously reported in the literature. In most cases, patients with parathyroid auto-infarction undergo parathyroidectomy. Those who are managed conservatively need to remain under close clinical and biochemical surveillance long-term as in most cases PHPT recurs, sometimes several years after auto-infarction.

Optic neuritis as presenting primary hypoparathyroidism.

Papilloedema and raised intracranial pressure have been frequently reported with hypoparathyroidism, but very rarely optic neuritis. We report a case of a 54-year-old male patient who presented with classical optic neuritis which is believed to be secondary to primary hypoparathyroidism.