Healthcare Challenges in the Management of Primary Aldosteronism in Southeast Asia.

OBJECTIVE: While guidelines have been formulated for the management of primary aldosteronism (PA), following these recommendations may be challenging in developing countries with limited healthcare access. Hence, we aimed to assess the availability and affordability of healthcare resources for managing PA in the Association of Southeast Asian Nations (ASEAN) region, which includes low-middle-income countries. DESIGN: We instituted a questionnaire-based survey to specialists managing PA, assessing the availability and affordability of investigations and treatment. Population and income status data were taken from the national census and registries. RESULTS: Nine ASEAN country members (48 respondents) participated. While screening with aldosterone-renin-ratio is performed in all countries, confirmatory testing is routinely performed in only six countries due to lack of facilities and local assays, and cost constraint. Assays are only locally available in four countries, and some centers have a test turnaround time exceeding three weeks. In seven countries (combined population of 442 million), adrenal vein sampling (AVS) is not routinely performed due to insufficient radiological facilities or trained personnel, and cost constraint. Most patients have access to adrenalectomy and medications. In six countries, the cost of AVS and adrenalectomy combined is >30% of its annual gross domestic product per capita. While most patients had access to spironolactone, it was not universally affordable. CONCLUSION: Large populations currently do not have access to the healthcare resources required for the optimal management of PA. Greater efforts are required to improve healthcare access and affordability. Future guideline revisions for PA may need to consider these limitations.

Lateral Peri-Implantitis: Successful Management via Guided Bone Regeneration at Mandibular First Molar Implant.

Infections occurring around implants are divided into marginal peri-implantitis and retrograde peri-implantitis (RPI). Marginal peri-implantitis starts in the crestal bone and progresses to the apical portion, and RPI starts in the apical bone and progresses to the coronal portion. However, lateral peri-implantitis (LPI) occurring on the side of the implant body has not yet been reported, and the cause is unclear. This 63-year-old male patient is a case of unusual bone resorption that occurred in the lateral portion of the implant body 26 months after lateral bone augmentation. The origin of LPI was an infection at the site of laterally augmented bone. Rather than implant removal, this report demonstrates an alternative treatment option of guided bone regeneration after the enucleation and detoxification of the implant surface with successful clinical and radiographic results for 2 years.

2021 Asia-Pacific Graves' Disease Consortium Survey of Clinical Practice Patterns in the Management of Graves' Disease.

AIM: Although Graves' disease (GD) is common in endocrine practices worldwide, global differences in diagnosis and management remain. We sought to assess the current practices for GD in countries across Asia and the Pacific (APAC), and to compare these with previously published surveys from North America and Europe. METHODS: A web-based survey on GD management was conducted on practicing clinicians. Responses from 542 clinicians were received and subsequently analysed and compared to outcomes from similar surveys from other regions. RESULTS: A total of 542 respondents participated in the survey, 515 (95%) of whom completed all sections. Of these, 86% were medical specialists, 11% surgeons, and 3% nuclear medicine physicians. In addition to serum thyroid-stimulating hormone (TSH) and free thyroxine assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (68%) during initial work-up. Thyroid ultrasound is requested by about half of respondents (53%), while the use of nuclear medicine scans is limited. The preferred first-line treatment is anti-thyroid drug (ATD) therapy (79%) with methimazole (MMI) or carbimazole (CBZ), followed by radioiodine (RAI; 19%) and surgery (2%). In case of surgery, one-third of respondents would opt for a subtotal rather than a total thyroidectomy. In case of mild Graves orbitopathy (GO), ATDs (67%) remains the preferred treatment, but a larger proportion of clinicians prefer surgery (20%). For a patient with intention to conceive, the preferred treatment pattern remained unchanged, although propylthiouracil (PTU) became the preferred ATD-agent during the first trimester. In comparison to European and American practices, marked differences were noted in the relatively infrequent usage of nuclear medicine scans and the overall higher use of a ATDs and ß-blockers and adjunctive ATD-treatment during RAI in the APAC-group. CONCLUSION: Although regional differences regarding the diagnosis and management of GD are apparent in this first pan-Asia-Pacific survey, this study reveals the overall approach to the management of this disease in Asia-Pacific generally tends to fall between the trends appreciated in the American and European cohorts.

The Multicenter, Open-Label, Observational LEAD-Ph Study: Real-World Safety and Effectiveness of Liraglutide in Filipino Participants with Type 2 Diabetes.

OBJECTIVE: Assess safety and effectiveness of liraglutide among Filipino participants with type 2 diabetes (T2D) in routine clinical practice. METHODOLOGY: A 26-week, prospective, multicenter, open-label, observational study was conducted in adults with T2D prescribed liraglutide (1.2 mg or 1.8 mg) in routine clinical practice in the Philippines. Primary endpoint: incidence rate and type of serious adverse drug reactions (SADRs). Secondary endpoints included other aspects of safety, and effectiveness. RESULTS: Participants (n=1056) had a mean (standard deviation) age of 53.2 (12.0) years, and glycated hemoglobin (HbA1c) level of 8.8% (2.0). Of 19 ADRs reported in 17 participants, none were SADRs (primary endpoint). No serious adverse events were reported. From baseline to week 26: the proportion of participants with major hypoglycemic episodes (requiring assistance) decreased from 2.0% to 0.2%; and with minor episodes (plasma glucose <3.1 mmol/L [<56 mg/dL]) decreased from 6.1% to 1.5%; serum creatinine remained unchanged. Among secondary effectiveness endpoints, improvements were seen from baseline to week 26 in HbA1c level, fasting and postprandial blood glucose levels, body weight, blood pressure, and fasting lipid profile. CONCLUSION: During routine clinical use of liraglutide for T2D in the Philippines, no new safety concerns were identified and blood glucose was lowered effectively.

Ultrasound features of thyroid nodules predictive of thyroid malignancy as determined by fine needle aspiration biopsy

INTRODUCTION: Current guidelines recommend that in patients presenting with clinically palpable nodules or with an ultrasound finding of a thyroid nodule, one has to evaluate its risk for malignancy by proceeding with a fine needle aspiration biopsy (FNAB). The decision to do FNAB would depend on ultrasonographic features of the nodule, which include its size, hypoechogenicity, presence of microcalcifications, increased central vascularity, infiltrative margins, and taller than wide measures on transverse plane. Elastography, a measure of tissue stiffness, is now also being utilized as another feature that has a positive correlation with malignancy. This study hopes to determine which among the abovementioned ultrasonographic features would best correlate with a higher risk for thyroid malignancy among adult patients who had undergone ultrasound guided FNAB.METHODOLOGY: A prospective study was done in a cohort of all Filipino patients 19 years old and above who underwent ultrasound guided FNAB of the thyroid nodule/s from July to December 2013 at the Radiology Section of The Medical City, Pasig City, Philippines. Specimen obtained from FNAB were then reviewed by a pathologist to determine its cytopathology and categorized based on the Bethesda System of Classification. The cytopathology reports were correlated with the features seen on the patient's thyroid ultrasound to determine which characteristic would be predictive of malignancy.RESULTS: A total of 100 patients underwent ultrasoundguided FNAB, from which 157 nodules were biopsied. 27 nodules were excluded from the analysis due to non-diagnostic or unsatisfactory (Bethesda Category I) findings on cytopathology. Among the 100 patients, 86% of which were females with the mean age of 41 ± 11.31 in those found to have malignant cytopathologic diagnosis. Of the 130 nodules biopsied, 115 nodules were identified as benign (Bethesda Category II) while 15 were identified to be malignant or suspicious for malignancy (Bethesda Category III-VI). Each of the five sonographic features that were predictive of malignancy was compared between the two outcome groups (benignversus malignant). Among them, only the presence of microcalcifications on ultrasound showed to be significantly correlated with malignancy with an odds ratio of 11.3. Ultrasound evaluation with elastography was only performed on 24 nodules and hence results were inconclusive. A nodule possessing more than two of the ultrasound features that were predictive of malignancy was more likely to be malignant on cytopathology (p value of 0.00).CONCLUSION: The presence of microcalcifications on thyroid nodules as seen on ultrasound is a significant predictor of malignancy and remains to be consistent locally as with foreign studies. Nodules that were proven to be malignant on cytopathology presented with more of the ultrasound features that are said to be predictive of malignancy.

Endocrine malignancies: A five-year retrospective analysis in a tertiary hospital

BACKGROUND: Endocrine malignancy in the Filipino population has not been well documented particularly on the incidence, prevalence, demographic profile and survival rate. It is the aim of this study to determine the prevalence rate and demographic profile of all endocrine malignancies diagnosed at a tertiary hospital.MATERIALS AND METHODS: This is a retrospective study from March 2003 to March 2008. Data were obtained from the Tumour Registry of St. Luke's Medical Center Cancer Institute (SLMC-CI) and from the Annual Report of the Diabetes, Thyroid and Endocrinology Center (DTEC) Section of SLMC-Quezon City. Only individuals with retrievable histopathology at this institution were included in the study.STATISTICAL ANALYSIS: Data were calculated using percentages and proportions.RESULTS: There were a total of 855 cases of endocrine malignancies documented in five years of which, 833 were cases of thyroid malignancies (97.4%). Fourteen cases of adrenal cancer (1.60%), seven cases of neuroendocrine carcinoma (0.79%), and one case of parathyroid carcinoma (0.14%). There was no note of pituitary cancer. There were a total of 833 newly diagnosed thyroid cancer: 652 papillary carcinoma (78.2%), 157 follicular carcinoma (18.8%), 11 anaplastic carcinoma (1.32%); nine medullary thyroid cancer (1.08%); two thyroid lymphoma (0.28%), one poorly differentiated carcinoma (0.14%) and one metastatic to the thyroid (0.14%). Among the 14 adrenal cancers, seven cases were due to adrenal cortical carcinoma, one case was due to adrenal neuroblastoma and six cases were due to adrenal metastases. Among the neuroendocrine carcinomas, four were pancreatic neuroendocrine carcinoma which included two malignant insulinoma and three patients were extra pancreatic neuroendocrine carcinoma.

Primary hyperparathyroidism during pregnancy: A case report

BACKGROUND: Primary hyperparathyroidism is considered rare in pregnancy, and only about 200 cases have so far been reported in world literature. Severe adverse effects can occur to both the mother and fetus if left untreated. Parathyroidectomy remains the definitive treatment. We present a diagnosed case of primary hyperparathyroidism who underwent a minimally invasive parathyroidectomy with intraoperative PTH monitoring in the third trimester of pregnancy.                                                                                                                                                          CASE: A 38 year old female consulted our clinic due to a history of recurrent Urinary Tract Infection (UTI) and bilateral nephrolithiasis. Investigation revealed an ionized calcium level of 1.59mg/dl (normal value 1.05-1.25 mg/dl), and an intact PTH of 257 pg/ml. A parathyroid scintigraphy using Tc99m-sestamibi was done revealing a focal radioavid mass lesion immediately inferior to the left thyroid fossa, consistent with a parathyroid adenoma, approximately measuring 1.6cm x 1.1cm. She was advised surgical excision but opted to postpone surgery and medical therapy instead. After eight months, she followed up in our clinic, 30 weeks pregnant, with symptoms of nausea, vomiting and recurrent UTI. With recent ionized calcium of 1.6mg/dl, she agreed to the removal of the parathyroid tumor. Prior to her scheduled surgery, hydration was done and IV glucocorticoids were given to mature the lung surfactant of the fetus in case of premature labor induced by parathyroidectomy. At 34 weeks of gestation, patient underwent minimally invasive parathyroidectomy which revealed a parathyroid adenoma. Before the excision, intact PTH level was 877 pg/ml and 10 minutes after excision, the intact PTH dropped to 48.8 pg/ml. When the ionized calcium level dropped to 1.03 mg/dl post-operatively, the patient experienced mild transient abdominal contractions and with slight tingling sensation over the face. Calcium supplementation was given which normalized calcium levels. The patient subsequently had an uneventful postoperative recovery and had an uneventful antenatal course.CONCLUSION: Surgeries for hyperparathyroidism in pregnant women are usually performed in the second trimester of pregnancy, on the other hand there is an ongoing debate regarding the safety performed during the third trimester of pregnancy. We presented a case that was successfully performed during the third trimester with minimally invasive parathyroidectomy. We also present this case due to its rare occurrence and discussed the preoperative management of pregnant patients with proper hyperparathyroidism.

Case detection of primary aldosteronism using the aldosterone-renin ratio (ARR): A three year experience in a tertiary hospital

BACKGROUND: Primary aldosteronism is a common, treatable and potentially curable cause of hypertension. It is a much more common cause of hypertension than was previously thought, and aldosterone excess may have deleterious effects on the cardiovascular system that are at least partly independent of blood pressure elevation. Plasma aldosterone-renin ratio is currently the most reliable available screening test for primary aldosteronism.OBJECTIVE: To determine the cases of primary aldosteronism using aldosterone-renin ratio as screening tool.METHODOLOGY: This is a retrospective, descriptive study. Seventy-two charts of patients with plasma aldosterone and renin determination done were reviewed.RESULTS: Forty-three patients had positive aldosterone-renin ratio (ARR?30). Only 23 submitted to a confirmatory test. Eighteen were females. The mean age was 40 y.o; the mean duration of onset of hypertension was 5 years prior to consult. Mean systolic and diastolic BP were 195mmHg and 100mmHg, respectively. All were hypokalemic. Fourteen showed a positive result in confirmatory saline infusion test. Computed tomography was done. Ten had unilateral adrenal nodule, 2 had adrenal limb thickening and 2 had bilateral adrenal lesions. Those with bilateral lesions underwent bilateral adrenal vein sampling, but no lateralization was demonstrated. They were given medical therapy, as well as the other 2 with adrenal limb thickening. The ten patients with unilateral adrenal lesions underwent unilateral adrenalectomy. Serum potassium normalized postoperatively; blood pressure improved but 3 patients continued to maintain on antihypertensive medication after surgery.CONCLUSIONS: Primary aldosteronism is a potentially curable disease. Hypokalemia and blood pressure improve upon treatment. Case detection using plasma aldosterone-renin ratio be done in high risk group. Confirmatory test must be pursued in those with positive ratio. CT scan is helpful in detecting the lesion and adrenal vein sampling be done to lateralize the hyperfunctioning adrenal.

Anaplastic thyroid carcinoma with destructive thyrotoxicosis in a patient with preexisting multinodular goiter.

Presentation of anaplastic thyroid carcinoma with thyrotoxicosis is extremely rare and its occurrence in a patient with Wegener's granulomatosis has not been reported previously. We describe an elderly lady with Wegener's granulomatosis who developed a rapidly growing anaplastic thyroid carcinoma in a preexisting multinodular goiter and discuss the mechanism of thyrotoxicosis in this patient.