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Loh WJ, Soh HS, Tun MH, Tan PT, Lau CS, Tavintharan S, Watts GF, Aw TC. Elevated remnant cholesterol and non-HDL cholesterol concentrations from real-world laboratory results: a cross-sectional study in Southeast Asians. Front Cardiovasc Med 2024; 11:1328618. [PMID: 38385128 PMCID: PMC10879277 DOI: 10.3389/fcvm.2024.1328618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/22/2024] [Indexed: 02/23/2024] Open
Abstract
Introduction Triglyceride-rich remnant lipoproteins (TRLs) are considered atherogenic due to the presence of remnant cholesterol, which is transported by apolipoprotein B. In clinical practice, the concentration of TRLs can be estimated by calculating remnant cholesterol or non-HDL cholesterol levels. Aim This study aims to investigate the proportion of patients who have low LDL cholesterol (LDL-C) concentration but elevated remnant cholesterol concentration, stratified by the presence of hypertriglyceridaemia and ethnicity, using real-world hospital data. Our secondary aim is to investigate the proportion of patients with elevated non-HDL cholesterol levels using guideline-recommended goals. Methods A 2-year retrospective study was conducted at a single centre, analyzing lipid blood tests of all patients, including directly measured LDL-C. Fasting for blood tests was not mandatory. Results The study included a total of 21,605 consecutive patients with plasma lipid profiles analyzed in our hospital laboratory. The median age was 61 years. In patients with ASCVD (n = 14,704), 23.7% had an LDL-C level of <1.8 mmol/L, 11.3% had elevated remnant cholesterol concentrations at ≥0.65 mmol/L, and 48.8% were at the non-high-density lipoprotein cholesterol (non-HDL-C) goal (<2.6 mmol/L). Among patients diagnosed with atherosclerotic cardiovascular disease (ASCVD) with LDL-C levels of <1.8 mmol/L (n = 3,484), only 11.9% had high levels of remnant cholesterol, but 96% of the ASCVD patients also achieved the recommended non-HDL-C target of <2.6 mmol/L. When the LDL-C level was <1.8 mmol/L, the mean concentration of remnant cholesterol was 0.214 mmol/L when the triglyceride level was <1.7 mmol/L (n = 3,380), vs. 0.70 mmol/L when the triglyceride level was elevated (n = 724), p < 0.001. Among patients with a triglyceride level of ≥1.7 mmol/L and an LDL-C level of <.8 mmol/L, there were 254 patients with elevated remnant cholesterol concentration and 71 patients with suboptimal non-HDL levels. Malays had a higher mean remnant cholesterol concentration compared with both Chinese and Indians across all LDL-C levels, particularly in the presence of hypertriglyceridaemia. Conclusions An elevated remnant cholesterol concentration of >0.65 mmol/L was present in 11% of all patients. The current guideline-recommended non-HDL-C goal, which uses a 0.8 mmol/L estimate of remnant cholesterol concentration, was achieved in >92% of patients, suggesting that it is unlikely to be clinically useful for the majority of our patient population except where there is concomitant hypertriglyceridaemia. Further studies are needed to establish the appropriate non-HDL-C goal or calculated remnant cholesterol concentration, paired with the LDL-C goal or otherwise, in a Southeast Asian population.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Heng Samuel Soh
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Mon Hnin Tun
- Health Services Research Unit, Changi General Hospital, Singapore, Singapore
| | - Pei Ting Tan
- Clinical Trial and Research Unit, Changi General Hospital, Singapore, Singapore
| | - Chin Shern Lau
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, WA, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Tar Choon Aw
- Duke-NUS Medical School, Singapore, Singapore
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
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Loh WJ, Yaligar J, Hooper AJ, Sadananthan SA, Kway Y, Lim SC, Watts GF, Velan SS, Leow MKS, Khoo J. Clinical and imaging features of women with polygenic partial lipodystrophy: a case series. Nutr Diabetes 2024; 14:3. [PMID: 38321009 PMCID: PMC10847407 DOI: 10.1038/s41387-024-00260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 01/13/2024] [Accepted: 01/19/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Familial partial lipodystrophy (FPLD) is an inherited disorder of white adipose tissue that causes premature cardiometabolic disease. There is no clear diagnostic criteria for FPLD, and this may explain the under-detection of this condition. AIM This pilot study aimed to describe the clinical features of women with FPLD and to explore the value of adipose tissue measurements that could be useful in diagnosis. METHODS In 8 women with FPLD and 4 controls, skinfold measurements, DXA and whole-body MRI were undertaken. RESULTS Whole genome sequencing was negative for monogenic metabolic causes, but polygenic scores for partial lipodystrophy were elevated in keeping with FPLD type 1. The mean age of diagnosis of DM was 31 years in the FPLD group. Compared with controls, the FPLD group had increased HOMA-IR (10.3 vs 2.9, p = 0.028) and lower mean thigh skinfold thickness (19.5 mm vs 48.2 mm, p = 0.008). The FPLD group had lower percentage of leg fat and an increased ratio of trunk to leg fat percentage on DXA. By MRI, the FPLD group had decreased subcutaneous adipose tissue (SAT) volume in the femoral and calf regions (p < 0.01); abdominal SAT, visceral adipose tissue, and femoral and calf muscle volumes were not different from controls. CONCLUSION Women with FPLD1 in Singapore have significant loss of adipose but not muscle tissue in lower limbs and have early onset of diabetes. Reduced thigh skinfold, and increased ratio of trunk to leg fat percentage on DXA are potentially clinically useful markers to identify FPLD1.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
| | - Jadegoud Yaligar
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore, Singapore
| | - Amanda J Hooper
- Department of Biochemistry, Pathwest and Fiona Stanley Hospital Network, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
| | - Suresh Anand Sadananthan
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore, Singapore
| | - Yeshe Kway
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore, Singapore
- Departments of Medicine and Physiology, NUS Yong Loo School of Medicine, NUS, Singapore, Singapore
| | - Su Chi Lim
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
| | - Sambasivam Sendhil Velan
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore, Singapore
- Departments of Medicine and Physiology, NUS Yong Loo School of Medicine, NUS, Singapore, Singapore
| | - Melvin Khee Shing Leow
- Duke-NUS Medical School, Singapore, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore, Singapore
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- LKC School of Medicine, NTU, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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Loh WJ, Pang J, Chakraborty A, Ward NC, Chan DC, Hooper AJ, Bell DA, Burnett JR, Martin AC, Watts GF. Cascade testing of children and adolescents for elevated Lp(a) in pedigrees with familial hypercholesterolaemia. J Clin Lipidol 2024; 18:e33-e37. [PMID: 38040538 DOI: 10.1016/j.jacl.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/09/2023] [Indexed: 12/03/2023]
Abstract
Elevated plasma lipoprotein(a) [Lp(a)] is a common, inherited condition independently causing cardiovascular disease. Recent expert recommendations suggest opportunistically testing for elevated Lp(a) during cascade testing for familial hypercholesterolaemia (FH). We investigated the effectiveness of detecting elevated Lp(a) in 103 children and adolescents who were first-degree relatives of 66 adult index FH cases as part of an established FH cascade screening program. The yield of detection of elevated Lp(a) using a threshold of ≥30 mg/dL in children and adolescents was assessed. Cascade testing from FH index cases with elevated Lp(a) ≥50 mg/dL identified 1 case of Lp(a) ≥30 mg/dL for every 2 children or adolescents tested. In contrast, opportunistic screening from index cases with FH but normal Lp(a) levels demonstrated 1 case of Lp(a) ≥30 mg/dL for every 7.5 children or adolescents tested (p < 0.001). In conclusion, cascade testing for elevated Lp(a) from index cases with FH and elevated Lp(a) is effective in identifying new cases of elevated Lp(a).
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Endocrinology, Changi General Hospital, Singapore (Dr Loh); Duke-NUS Medical School, Singapore (Dr Loh).
| | - Jing Pang
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Anindita Chakraborty
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Natalie C Ward
- Dobney Hypertension Centre, Medical School, University of Western Australia (Dr Ward)
| | - Dick C Chan
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts)
| | - Amanda J Hooper
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Biochemistry, Royal Perth Hospital and Fiona Stanley Hospital Network, Pathwest Laboratory Medicine, Perth, Australia (Drs Hooper, Bell)
| | - Damon A Bell
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Biochemistry, Royal Perth Hospital and Fiona Stanley Hospital Network, Pathwest Laboratory Medicine, Perth, Australia (Drs Hooper, Bell); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
| | - John R Burnett
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
| | - Andrew C Martin
- School of Paediatrics and Child Health, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia (Dr Martin); Department of General Paediatrics, Perth Children's Hospital, Perth, Western Australia, Australia (Dr Martin)
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia (Drs Loh, Pang, Chakraborty, Chan, Hooper, Bell, Burnett, Watts); Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia (Drs Bell, Burnett, Watts)
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Gupta G, Teo AED, Swee DS, Loh LM, Chuah M, Loh WJ, Saffari SE, Koh XH, Kek PC, Puar TH. Prolonged Hypokalemia and Delayed Diagnosis of Primary Aldosteronism: Clinical Course and Risk Factors. J Clin Endocrinol Metab 2023:dgad752. [PMID: 38134306 DOI: 10.1210/clinem/dgad752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/01/2023] [Accepted: 12/19/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Primary Aldosteronism (PA) is a common cause of hypertension. However, diagnosis is often delayed, leading to poorer clinical outcomes. Hypokalemia with hypertension is characteristic of PA, and is an indication for screening. We evaluated if patients with PA had prolonged hypokalemia before diagnosis, the subsequent biochemical/clinical control, and factors associated with delayed diagnosis. METHODS Our study included all PA patients with hypokalemia diagnosed between 2001 to 2022. Delayed diagnosis was defined as duration of hypokalemia of >1 year from first occurrence, to first evaluation by a PA specialist. Patients were reassessed post-adrenalectomy using the Primary Aldosteronism Surgery Outcomes criteria. We performed multivariable analysis to assess for factors associated with delayed diagnosis. RESULTS Among 240 patients with PA who presented with hypokalemia, 122 (51%) patients had delayed diagnosis, with prolonged hypokalemia of median duration 4.5 (2.4-7.5) years. Patients with delayed diagnosis were older, had longer duration of hypertension, higher pill burden, lower renal function and more prevalent cardiovascular disease. Factors associated with delayed diagnosis included older age, presence of hyperlipidaemia, and less severe hypokalemia (serum potassium >3.0mmol/L). Compared to patients with early diagnosis, a lower proportion of those with delayed diagnosis underwent adrenal vein sampling (73% vs 58%), P<0.05. Sixty of 118 (50.8%) non-delayed, and 39 of 122 (32.0%) patients with delayed diagnosis underwent surgery. CONCLUSION Despite manifestation of hypokalemia, many patients with PA fail to be promptly screened. Greater emphasis in hypertension guidelines, and efforts to improve awareness of PA amongst primary care physicians are urgently needed.
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Affiliation(s)
- Gaytri Gupta
- Duke National University of Singapore (NUS) Medical School, Singapore
| | - Ada E D Teo
- Department of Endocrinology, National University Health System, Singapore
| | - Du Soon Swee
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Matthew Chuah
- Department of Endocrinology, Sengkang General Hospital, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Seyed Ehsan Saffari
- Duke National University of Singapore (NUS) Medical School, Singapore
- National Neuroscience Institute, Singapore
| | - Xuan Han Koh
- Health Science Research Department, Changi General Hospital, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Troy H Puar
- Duke National University of Singapore (NUS) Medical School, Singapore
- Department of Endocrinology, Changi General Hospital, Singapore
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Chua F, Lam A, Mak YH, Lee ZH, Dacay LM, Yew JL, Puar T, Khoo J, Chow W, Tan VH, Tong KL, Liew BW, Yeo C, Loh WJ. Undiagnosed cardiovascular risk factors including elevated lipoprotein(a) in patients with ischaemic heart disease. Front Epidemiol 2023; 3:1207752. [PMID: 38455910 PMCID: PMC10911051 DOI: 10.3389/fepid.2023.1207752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/29/2023] [Indexed: 03/09/2024]
Abstract
Objectives This study aims to investigate the prevalence of undiagnosed cardiovascular risk factors in patients with ischaemic heart disease (IHD). Methods We assessed the prevalence of previously undiagnosed cardiovascular risk factors, including elevated lipoprotein(a) [Lp(a)], among consenting patients with IHD who were admitted to hospital. Clinical information, including dietary history, from patients with newly diagnosed IHD and known IHD were compared. Results Of the 555 patients, 82.3% were males and 48.5% of Chinese ethnicity. Overall, 13.3% were newly diagnosed with hypertension, 14.8% with hypercholesterolemia, and 5% with type 2 diabetes (T2DM). Patients with newly diagnosed IHD, compared to those with known IHD, had a higher prevalence of new diagnoses of hypercholesterolemia (29.1% vs. 2.0%, p < 0.001), hypertension (24.5% vs. 3.4%, p < 0.001) and T2DM (7.3% vs. 3.1%, p = 0.023). Active smoking was prevalent in 28.3% of patients, and higher in newly diagnosed IHD (34.1% vs. 23.2%, p = 0.005). Elevated Lp(a) of ≥120 nmol/L was detected in 15.6% of all patients, none of whom were previously diagnosed. Dietary habits of >50% of patients in both groups did not meet national recommendations for fruits, vegetables, wholegrain and oily fish intake. However, patients with known IHD had a more regular omega-3 supplement intake (23.4% vs. 10.3%, p = 0.024). Conclusion Increased detection efforts is necessary to diagnose chronic metabolic diseases (hypertension, hypercholesterolemia, T2DM) especially among patients at high risk for IHD. Cardiovascular risk factors, in particular elevated Lp(a), smoking, and suboptimal dietary intake in patients with IHD deserve further attention.
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Affiliation(s)
- Fionn Chua
- Dietetics Department, Changi General Hospital, Singapore, Singapore
| | - Audrey Lam
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Ying Hui Mak
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Zhong Hui Lee
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Jie Lin Yew
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Troy Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Weien Chow
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Vern Hsen Tan
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Boon Wah Liew
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Colin Yeo
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Loh WJ, Watts GF. Detection strategies for elevated lipoprotein(a): will implementation let the genie out of the bottle? Curr Opin Endocrinol Diabetes Obes 2023; 30:94-102. [PMID: 36468313 DOI: 10.1097/med.0000000000000789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Elevated Lp(a) level is an important causal risk factor for atherosclerotic cardiovascular disease (ASCVD), principally coronary artery disease. Selective testing for Lp(a) is highly recommended in patients at intermediate and high risk for ASCVD. Lp(a) levels are predominantly genetically determined, and this has implications for cascade testing. RECENT FINDINGS Recent studies show that cascade testing is effective in identifying elevated Lp(a) in close relatives of probands with high Lp(a). Apart from selective testing and cascade testing as detection strategies, some recent guidelines recommend testing of Lp(a) in all adults at least once in their lifetime and various implementation strategies have been suggested. SUMMARY Hyper-Lp(a) is an important global health problem that can be easily detected. Hyper-Lp(a) meets all the criteria for universal screening except that there is not yet supportive evidence from clinical interventional trials showing a reduction of ASCVD events. The cost-effectiveness of the various detection and implementation strategies need to be further evaluated.
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Endocrinology, Changi General Hospital, Changi
- Duke-NUS Medical School, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Loh WJ, Watts GF. Xenosterolemia in clinical practice: what is in a name? Curr Opin Endocrinol Diabetes Obes 2023; 30:123-127. [PMID: 36597814 DOI: 10.1097/med.0000000000000795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to assess the potential value of the measurement of plasma xenosterols (or phytosterols) concentrations in clinical practice. RECENT FINDINGS Recent genetic studies suggest that individuals with elevated plasma phytosterol concentrations due to monogenic and polygenic variants are at an increased risk of coronary artery disease. This supports early observations that elevated plasma phytosterol concentrations are per se atherogenic. SUMMARY Measurement of plasma phytosterols can identify individuals with xenosterolemia (or phytosterolemia). This may be clinically useful in four ways: Establishing a diagnosis and informing management of patients with homozygous phytosterolemia; Providing a comprehensive differential diagnosis for familial hypercholesterolemia; Providing an index of cholesterol absorption that may inform personalized pharmacotherapy; and Informing more precise assessment of risk of cardiovascular disease.
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Endocrinology, Changi General Hospital, Changi
- Duke-NUS Medical School, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
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Loh WJ, Watts GF. The Management of Hypercholesterolemia in Patients with Neuromuscular Disorder. Curr Atheroscler Rep 2023; 25:43-53. [PMID: 36609642 DOI: 10.1007/s11883-022-01077-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW We describe and discuss the safety of statins and non-statin drugs in neuromuscular disorders (NMDs). We also propose a pragmatic model of care for the management of such cases. RECENT FINDINGS Patients with both NMD and hypercholesterolemia may be particularly disadvantaged owing to the toxic effects of cholesterol-lowering therapy and the inability to take medication. Specifically, the management of hypercholesterolemia in patients with NMD is complicated by the increased risk of statin-related myotoxicity and concerns that statins may aggravate or possibly induce the onset of a specific NMD. The most severe form of statin-related myotoxicity is immune-mediated necrotizing myopathy. Management of hypercholesterolemia in patients with NMDs include treating modifiable factors, consideration of toxicity risk of statin, use of non-statin lipid lowering agents, noting possible drug interactions, and careful monitoring.
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Affiliation(s)
- Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, WA, 6001, Australia. .,Cardiometabolic Service, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia. .,Department of Endocrinology, Changi General Hospital, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, WA, 6001, Australia.,Cardiometabolic Service, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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Seah S, Tan YK, Teh K, Loh WJ, Tan PT, Goh LC, Malakar RD, Aw TC, Lau CS, Dhalliwal T, Kui SL, Kam JW, Khoo J, Tay TL, Tan E, Au V, Soh SB, Zhang M, King TF, Gani L, Puar TH. Proton-pump inhibitor use amongst patients with severe hypomagnesemia. Front Pharmacol 2023; 14:1092476. [PMID: 36794273 PMCID: PMC9922884 DOI: 10.3389/fphar.2023.1092476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
Introduction: Long-term proton pump inhibitor (PPI) use has been associated with hypomagnesemia. It is unknown how frequently PPI use is implicated in patients with severe hypomagnesemia, and its clinical course or risk factors. Methods: All patients with severe hypomagnesemia from 2013 to 2016 in a tertiary center were assessed for likelihood of PPI-related hypomagnesemia using Naranjo algorithm, and we described the clinical course. The clinical characteristics of each case of PPI-related severe hypomagnesemia was compared with three controls on long-term PPI without hypomagnesemia, to assess for risk factors of developing severe hypomagnesemia. Results: Amongst 53,149 patients with serum magnesium measurements, 360 patients had severe hypomagnesemia (<0.4 mmol/L). 189 of 360 (52.5%) patients had at least possible PPI-related hypomagnesemia (128 possible, 59 probable, two definite). 49 of 189 (24.7%) patients had no other etiology for hypomagnesemia. PPI was stopped in 43 (22.8%) patients. Seventy (37.0%) patients had no indication for long-term PPI use. Hypomagnesemia resolved in most patients after supplementation, but recurrence was higher in patients who continued PPI, 69.7% versus 35.7%, p = 0.009. On multivariate analysis, risk factors for hypomagnesemia were female gender (OR 1.73; 95% CI: 1.17-2.57), diabetes mellitus (OR, 4.62; 95% CI: 3.05-7.00), low BMI (OR, 0.90; 95% CI: 0.86-0.94), high-dose PPI (OR, 1.96; 95% CI: 1.29-2.98), renal impairment (OR, 3.85; 95% CI: 2.58-5.75), and diuretic use (OR, 1.68; 95% CI: 1.09-2.61). Conclusion: In patients with severe hypomagnesemia, clinicians should consider the possibility of PPI-related hypomagnesemia and re-examine the indication for continued PPI use, or consider a lower dose.
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Affiliation(s)
- Sherry Seah
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yen Kheng Tan
- Doctor of Medicine Programme, Duke-NUS (National University School) Medical School, Singapore, Singapore
| | - Kevin Teh
- Department of Gastroenterology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Pei Ting Tan
- Department of Clinical Trial Research Unit, Changi General Hospital, Singapore, Singapore
| | - Leng Chuan Goh
- Department of Pharmacy, Changi General Hospital, Singapore, Singapore
| | | | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Chin Shern Lau
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Trishpal Dhalliwal
- Department of Internal Medicine, Changi General Hospital, Singapore, Singapore
| | - Swee Leng Kui
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Jia Wen Kam
- Department of Clinical Trial Research Unit, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Vanessa Au
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Shui Boon Soh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Thomas F. King
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Troy H. Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore,*Correspondence: Troy H. Puar,
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Teo CB, Gan MY, Tay RYK, Loh WJ, Loh NHW. Association of preoperative hyponatremia with surgical outcomes: a systematic review and meta-analysis of 32 observational studies. J Clin Endocrinol Metab 2022; 108:1254-1271. [PMID: 36472931 PMCID: PMC10099166 DOI: 10.1210/clinem/dgac685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Preoperative hyponatremia is prevalent in patients undergoing surgical procedures, but it is uncertain if hyponatremia will lead to increased risk of surgical mortality and morbidity. METHODS A systematic search of Medline (PubMed), Embase and Cochrane Library from inception till 2 July 2021 was performed. Full length articles that reported on the association between surgical outcomes among adults ≥18 years with documented preoperative hyponatremia were included. FINDINGS We identified 32 observational studies comprising 1,301,346 participants. All studies had low risk of bias. When adjusted for covariates, patients with hyponatremia had significantly higher odds of developing major complications (defined as a composite measure of 9 major complications) compared to patients with normal sodium concentrations (aOR = 1.37, 95%CI = 1.23-1.53, I2 = 78%. N = 10). Additionally, patients with preoperative hyponatremia also significantly higher hazards of early mortality (<90 days) compared to patients with normonatremia (aHR = 1.27, 95%CI = 1.13-1.43, I2 = 97%. N = 10) after adjustment for covariates. Preoperative hyponatremia also had significant associations with respiratory, renal and septic complications. In terms of prognostic performance, preoperative hyponatremia performed adequately in predicting major complications in surgical patients (AUC = 0.70, LR- 0.90) with a specificity of 88% and a sensitivity of 25%. INTERPRETATION Our meta-analysis suggests that preoperative hyponatremia is associated with poorer early mortality and major morbidity outcomes in surgical patients. Hyponatremia is also a specific prognosticator for major complications in surgical patients, reiterating its potential use as a clinical indicator of poor outcomes.
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Affiliation(s)
- Chong Boon Teo
- Ministry of Health Holdings, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Ne-Hooi Will Loh
- Department of Anaesthesia, National University Hospital, Singapore
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11
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Abstract
The status of lipoprotein (a) [Lp(a)] as a cardiovascular risk factor has been resurrected by advances in genetics. Mendelian randomization studies show a causal link of Lp(a) with coronary artery disease (CAD), peripheral artery disease (PAD), and calcific aortic valve stenosis (CAVS). The genetics of Lp(a) is complex and extends beyond the kringle-IV type 2, as it is also dependent on ancestry. The plasma concentration of Lp(a) is determined by the hepatic production of apolipoprotein(a) [apo(a)] component of Lp(a), supporting the use of nucleic acids that inhibit the messenger RNA (mRNA) gene transcript for apo(a). Analytical barriers to measurement of Lp(a) are being addressed using isoform independent assays and a traceable standard. The association of Lp(a) and atherosclerotic cardiovascular disease is higher for myocardial infarction than PAD and CAVS. Increased risk of type 2 diabetes mellitus associated with low Lp(a) levels is perplexing and requires further investigation. The greatest advancement in Lp(a)-lowering therapies is based on using RNA therapeutics that are now being investigated in clinical trials. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibition lowers Lp(a) modestly, but whether cardiovascular benefit is independent of low-density lipoprotein lowering remains unclear. Opportunistic and selective testing for Lp(a) is supported by moderate evidence, with the case for universal screening premature. Modification of behavioral and clinical risk factors may be targeted to mitigate Lp(a)-mediated risk of cardiovascular disease. Clinical practice guidelines have been developed to address gaps in care of high Lp(a), but full implementation awaits the findings of clinical outcome trials using RNA-directed therapies currently underway.
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Affiliation(s)
- Paul Nestel
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Wann Jia Loh
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
- Department of Endocrinology, Changi General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Natalie C Ward
- School of Medicine, University of Western Australia, Perth, Australia
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, Australia
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12
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Loh WJ, Bakthavachalam R, Subramaniam T, Pek S, Chua F, Lee L, Watts GF. Chylomicronemia through a burr hole: A case report. Front Cardiovasc Med 2022; 9:1020397. [PMID: 36312279 PMCID: PMC9596755 DOI: 10.3389/fcvm.2022.1020397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Chylomicronemia has either a monogenic or multifactorial origin. Multifactorial chylomicronemia is the more common form and is due to the interaction of genetic predisposition and secondary factors such as obesity, diabetes, unhealthy diet, and medications. We report a case of a 38-year-old man who was diagnosed with multifactorial chylomicronemia following presentation with a subarachnoid hemorrhage requiring emergency surgery through a burr hole; lactescent cerebrospinal fluid mixed with blood was observed through the burr hole. The serum triglyceride concentration was 52⋅4 mmol/L with a detectable triglyceride concentration in the cerebrospinal fluid. Rapid weight gain leading to obesity and related unfavorable lifestyle factors were identified as key secondary causes of chylomicronemia. Gene testing revealed a homozygous variant in APOA5 and a heterozygous common variant in GPIHBP1. Accompanied with secondary causes, the interactions of gene and environmental conditions contribute to chylomicronemia. With aggressive medical treatment including excess weight loss, healthy diet, cessation of alcohol, and combination of anti-lipemic medications, normal plasma triglyceride levels were achieved.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore,Medical School, University of Western Australia, Perth, WA, Australia,Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia,Duke-NUS Medical School, Singapore, Singapore,*Correspondence: Wann Jia Loh, ;
| | | | - Tavintharan Subramaniam
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore,Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sharon Pek
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fionn Chua
- Department of Dietetics, Changi General Hospital, Singapore, Singapore
| | - Lester Lee
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Gerald F. Watts
- Medical School, University of Western Australia, Perth, WA, Australia,Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
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13
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Loh WJ, Watts GF. The Inherited Hypercholesterolemias. Endocrinol Metab Clin North Am 2022; 51:511-537. [PMID: 35963626 DOI: 10.1016/j.ecl.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Inherited hypercholesterolemias include monogenic and polygenic disorders, which can be very rare (eg, cerebrotendinous xanthomatosis (CTX)) or relatively common (eg, familial combined hyperlipidemia [FCH]). In this review, we discuss familial hypercholesterolemia (FH), FH-mimics (eg, polygenic hypercholesterolemia [PH], FCH, sitosterolemia), and other inherited forms of hypercholesterolemia (eg, hyper-lipoprotein(a) levels [hyper-Lp(a)]). The prevalence, genetics, and management of inherited hypercholesterolemias are described and selected guidelines summarized.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia 6009, Australia; Department of Cardiology and Internal Medicine, Royal Perth Hospital, Victoria Square, Perth, Western Australia 6000, Australia
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14
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Teo CB, Tan PY, Tay RYK, Khoo J, Watts GF, Loh WJ. Association Between Vitamin D Supplementation and Statin-Associated Muscle Symptoms: A Systematic Review. High Blood Press Cardiovasc Prev 2022; 29:337-351. [PMID: 35768686 DOI: 10.1007/s40292-022-00526-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Although low vitamin D levels are associated with statin-associated muscle symptoms (SAMS), it remains unclear if vitamin D supplementation leads to symptom improvement. AIM We performed a systematic review to evaluate the association of vitamin D supplementation with resolution of SAMS. METHODS We searched Medline (PubMed), Embase and Cochrane Library till 12 December 2021. Full length articles that reported on the association between vitamin D supplementation in adult patients with SAMS were included. RESULTS We identified 8 interventional studies comprising 669 participants. Majority of the participants were of Caucasian ethnicity and the mean age of participants ranged from 59.5 to 64.8 years old. The studies recruited patients with initial mean pre-treatment vitamin D levels ranging from 17.8 to 22.0ng/mL. Follow up duration ranged from 2 to 24 months and mean post-treatment vitamin D levels ranged from 34.3 to 56.0ng/mL. We found that vitamin D supplementation was associated with improved statin tolerance in 509 out of 606 (83.9%) patients across the 7 studies which reported patient numbers after supplementation (95% CI = 0.81-0.87, I2 = 72% n = 7). None of the studies were randomized controlled trials (RCTs) and hence placebo effect of vitamin D could not be ruled out. Nocebo effect of statin was also not assessed by any of the studies. CONCLUSION Vitamin D supplementation in patients with mild-moderate vitamin D insufficiency was associated with improvement of SAMS. However, quantitative efficacy analysis was not possible and this observed association is likely confounded by nocebo and placebo effects. RCTs are required to conclusively assess the utility of vitamin D supplementation in improving SAMS.
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Affiliation(s)
- Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pek Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ryan Yong Kiat Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, Perth, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Australia
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
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15
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Lee LMY, Tan SYT, Loh WJ. High Urinary Sodium Concentrations in Severe SIADH: Case Reports of 2 Patients and Literature Review. Front Med (Lausanne) 2022; 9:897940. [PMID: 35602488 PMCID: PMC9114638 DOI: 10.3389/fmed.2022.897940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/14/2022] [Indexed: 12/04/2022] Open
Abstract
We present two cases of severe hyponatremia secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH) with very high urine sodium concentrations (>130 mmol/L). The first patient had hyponatremia from traumatic brain injury (TBI) while the second case had a history of recurrent SIADH triggered by various causes including gastritis. In both cases, fluid administration and/or consumption worsened the hyponatremia. Although a low urine sodium of <30 mmol/L is highly suggestive of hypovolemic hyponatremia and good response to saline infusion, there is lack of clarity of the threshold of which high urine sodium concentration can differentiate various causes of natriuresis such as SIADH, renal or cerebral salt wasting. Apart from high urine osmolality (>500 mOsm/kg), persistence of high urine sodium concentrations may be useful to predict poor response to fluid restriction in SIADH. More studies are needed to delineate treatment pathways of patients with very high urine osmolality and urine sodium concentrations in SIADH.
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Affiliation(s)
- Lynette Mei Yi Lee
- Department of Endocrinology, Sengkang General Hospital, Singapore, Singapore
| | - Sarah Ying Tse Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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16
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Loh WJ, Chan DC, Mata P, Watts GF. Familial Hypercholesterolemia and Elevated Lipoprotein(a): Cascade Testing and Other Implications for Contextual Models of Care. Front Genet 2022; 13:905941. [PMID: 35571022 PMCID: PMC9091303 DOI: 10.3389/fgene.2022.905941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Elevated lipoprotein(a) [Lp(a)], a predominantly genetic disorder, is a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valvular disease, particularly in patients with familial hypercholesterolemia (FH), a Tier I genomic condition. The combination from birth of the cumulative exposure to elevated plasma concentrations of both Lp(a) and low-density lipoprotein is particularly detrimental and explains the enhanced morbidity and mortality risk observed in patients with both conditions. An excellent opportunity to identify at-risk patients with hyper-Lp(a) at increased risk of ASCVD is to test for hyper-Lp(a) during cascade testing for FH. With probands having FH and hyper-Lp(a), the yield of detection of hyper-Lp(a) is 1 individual for every 2.1-2.4 relatives tested, whereas the yield of detection of both conditions is 1 individual for every 3-3.4 relatives tested. In this article, we discuss the incorporation of assessment of Lp(a) in the cascade testing in FH as a feasible and crucial part of models of care for FH. We also propose a simple management tool to help physicians identify and manage elevated Lp(a) in FH, with implications for the care of Lp(a) beyond FH, noting that the clinical use of RNA therapeutics for specifically targeting the overproduction of Lp(a) in at risk patients is still under investigation.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Dick C Chan
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Pedro Mata
- Fundación Hipercolesterolemia Familiar, Madrid, Spain
| | - Gerald F Watts
- Medical School, University of Western Australia, Perth, WA, Australia.,Lipid Disorders Clinic, Department of Cardiology and Internal Medicine, Royal Perth Hospital, Perth, WA, Australia
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17
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Puar TH, Cheong CK, Foo RSY, Saffari SE, Tu TM, Chee MR, Zhang M, Ng KS, Wong KM, Wong A, Ng FC, Aw TC, Khoo J, Gani L, King T, Loh WJ, Soh SB, Au V, Tay TL, Tan E, Mae L, Yew J, Tan YK, Tong KL, Lee S, Chai SC. Treatment of Primary Aldosteronism and Reversal of Renin Suppression Improves Left Ventricular Systolic Function. Front Endocrinol (Lausanne) 2022; 13:916744. [PMID: 35846272 PMCID: PMC9279860 DOI: 10.3389/fendo.2022.916744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Primary aldosteronism (PA) is associated with increased risk of cardiovascular events. However, treatment of PA has not been shown to improve left ventricular (LV) systolic function using the conventional assessment with LV ejection fraction (LVEF). We aim to use speckle-tracking echocardiography to assess for improvement in subclinical systolic function after treatment of PA. METHODS We prospectively recruited 57 patients with PA, who underwent 24-h ambulatory blood pressure (BP) measurements and echocardiography, including global longitudinal strain (GLS) assessment of left ventricle, at baseline and 12 months post-treatment. RESULTS At baseline, GLS was low in 14 of 50 (28.0%) patients. On multivariable analysis, GLS was associated with diastolic BP (P = 0.038) and glomerular filtration rate (P = 0.026). GLS improved post-surgery by -2.3, 95% CI: -3.9 to -0.6, P = 0.010, and post-medications by -1.3, 95% CI: -2.6 to 0.03, P = 0.089, whereas there were no changes in LVEF in either group. Improvement in GLS was independently correlated with baseline GLS (P < 0.001) and increase in plasma renin activity (P = 0.007). Patients with post-treatment plasma renin activity ≥1 ng/ml/h had improvements in GLS (P = 0.0019), whereas patients with persistently suppressed renin had no improvement. Post-adrenalectomy, there were also improvements in LV mass index (P = 0.012), left atrial volume index (P = 0.002), and mitral E/e' (P = 0.006), whereas it was not statistically significant in patients treated with medications. CONCLUSION Treatment of hyperaldosteronism is effective in improving subclinical LV systolic dysfunction. Elevation of renin levels after treatment, which reflects adequate reversal of sodium overload state, is associated with better systolic function after treatment. CLINICAL TRIAL REGISTRATION www.ClinicalTrials.gov, identifier: NCT03174847.
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Affiliation(s)
- Troy H Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Chin Kai Cheong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Roger S Y Foo
- Genome Institute of Singapore, Singapore, Singapore
- Cardiovascular Research Institute , National University Health System, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine, Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Min Ru Chee
- Ministry of Health Holdings, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Keng Sin Ng
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | - Kang Min Wong
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | - Andrew Wong
- Department of Surgery, Changi General Hospital, Singapore, Singapore
| | - Foo Cheong Ng
- Department of Urology, Changi General Hospital, Singapore, Singapore
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Thomas King
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Shui Boon Soh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Vanessa Au
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Lily Mae
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Jielin Yew
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Yen Kheng Tan
- Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Sheldon Lee
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
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18
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Hua Tan CS, Ang SF, Yeoh E, Goh BX, Loh WJ, Shum CF, May Ping Eng M, Yan Lun Liu A, Wan Ting Chan L, Goh LX, Subramaniam T, Sum CF, Lim SC. MODY5 Hepatocyte Nuclear Factor 1ß (HNF1ß)-Associated Nephropathy: experience from a regional monogenic diabetes referral centre in Singapore. J Investig Med High Impact Case Rep 2022; 10:23247096211065626. [PMID: 35038894 PMCID: PMC8784948 DOI: 10.1177/23247096211065626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/11/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022] Open
Abstract
From our monogenic diabetes registry set-up at a secondary-care diabetes center, we identified a nontrivial subpopulation (~15%) of maturity-onset diabetes of the young (MODY) among people with young-onset diabetes. In this report, we describe the diagnostic caveats, clinical features and long-term renal-trajectory of people with HNF1B mutations (HNF1B-MODY). Between 2013 and 2020, we received 267 referrals to evaluate MODY from endocrinologists in both public and private practice. Every participant was subjected to a previously reported structured evaluation process, high-throughput nucleotide sequencing and gene-dosage analysis. Out of 40 individuals with confirmed MODY, 4 (10%) had HNF1B-MODY (harboring either a HNF1B whole-gene deletion or duplication). Postsequencing follow-up biochemical and radiological evaluations revealed the known HNF1B-MODY associated systemic-features, such as transaminitis and structural renal-lesions. These anomalies could have been missed without prior knowledge of the nucleotide-sequencing results. Interestingly, preliminary longitudinal observation (up to 15 years) suggested possibly 2 distinct patterns of renal-deterioration (albuminuric vs. nonalbuminuric chronic kidney disease). Monogenic diabetes like HNF1B-MODY may be missed among young-onset diabetes in a resource-limited routine-care clinic. Collaboration with a MODY-evaluation center may fill the care-gap. The long-term renal-trajectories of HNF1B-MODY will require further studies by dedicated registries and international consortium.
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Affiliation(s)
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | - Ester Yeoh
- Diabetes Centre, Admiralty Medical Centre, Singapore
| | - Bing Xing Goh
- Diabetes Centre, Admiralty Medical Centre, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Cheuk Fan Shum
- Department of Surgery, Woodlands Health Campus, Singapore
| | | | | | | | - Li Xian Goh
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
| | | | - Chee Fang Sum
- Diabetes Centre, Admiralty Medical Centre, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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19
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Teo CB, Tan PY, Lee SX, Khoo J, Tan JG, Ang SF, Tan SH, Tay TL, Tan E, Lim SC, Boehm BO, Loh WJ. Insulin Allergy to Detemir Followed by Rapid Onset of Diabetic Ketoacidosis: A Case Report and Literature Review. Front Endocrinol (Lausanne) 2022; 13:844040. [PMID: 35350098 PMCID: PMC8958006 DOI: 10.3389/fendo.2022.844040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 02/08/2022] [Indexed: 12/04/2022] Open
Abstract
The management of diabetes mellitus in an insulin-dependent patient is challenging in the setting of concomitant antibody-mediated-insulin hypersensitivity. We report a case of a 62-year-old woman with pre-existing type 2 diabetes mellitus of 10 years duration who developed type 3 hypersensitivity reaction to insulin analogue detemir, and subsequently, severe diabetic ketoacidosis (DKA). She was C-peptide negative and was diagnosed with insulin-dependent diabetes. Despite increasing dose adjustments, insulin-meal matching, and compliance with insulin, she experienced episodes of unexpected hyperglycaemia and hypoglycaemia. The development of rash after detemir initiation and rapid progression to DKA suggests an aberrant immune response leading to the insulin allergy and antibody-induced interference with insulin analogues. Glycaemic control in the patient initially improved after being started on subcutaneous insulin infusion pump with reduced insulin requirements. However, after a year on pump therapy, localised insulin hypersensitivity reactions started, and glycaemic control gradually deteriorated.
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Affiliation(s)
- Chong Boon Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Pek Yan Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shan Xian Lee
- Department of Dermatology, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Jun Guan Tan
- Department of Laboratory Medicine, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Sze Hwa Tan
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
| | - Bernhard O. Boehm
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore
- Type 1 Diabetes Genetics Consortium (T1DGC) European Repository, Ulm University, Ulm, Germany
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- *Correspondence: Wann Jia Loh,
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20
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Loh WJ, Chang X, Aw TC, Phua SK, Low AF, Chan MYY, Watts GF, Heng CK. Lipoprotein(a) as predictor of coronary artery disease and myocardial infarction in a multi-ethnic Asian population. Atherosclerosis 2021; 349:160-165. [PMID: 34887076 DOI: 10.1016/j.atherosclerosis.2021.11.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The role of Lp(a) in multi-ethnic Asian populations with coronary artery disease (CAD) has not been well established. The aims of this study were (i) to investigate whether Lp(a) is a predictor of CAD, and (ii) amongst patients with CAD, to ascertain whether Lp(a) is a predictor of acute myocardial infarction (AMI) and severity of CAD. METHODS We compared three cardiovascular phenotypes from patients recruited at coronary angiography. CAD was defined as ≥50% coronary artery stenosis and subdivided into a group with AMI history (CAD+AMI+) and a group without (CAD+AMI-). Minimal CAD group (CAD-) was defined as normal or <30% coronary artery stenosis and no AMI. The severity of CAD was defined using the modified Gensini score. RESULTS We studied 2025 patients comprising 94.5% men and 61.4% of Chinese ethnicity. The median Lp(a) level was highest in CAD+AMI+, followed by CAD+AMI- and CAD- (26.2, 20.1, and 15.8 nmol/L respectively). Similarly, the frequency of patients with Lp(a) ≥120 nmol/L were in the same order (11.8%, 9.1% and 2.4%). Lp(a) levels were highest among Asian Indians, followed by Malays and Chinese patients (p < 0.001). Lp(a) levels and Lp(a) ≥120 nmol/L were significant predictors of CAD (Odds ratio (OR) = 1.12 per 10 nmol/L increment, p < 0.001, and OR = 5.41 p = 0.004 respectively). Among patients with CAD, higher Lp(a) levels were associated with increased AMI risk (OR = 1.02 per 10 nmol/L increment, p = 0.024). Lp(a) ≥120 nmol/L was positively associated with CAD severity (p = 0.020). CONCLUSIONS Plasma Lp(a) concentration is a positive predictor of CAD and AMI in a mostly male South East Asian population.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
| | - Xuling Chang
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
| | - Tar Choon Aw
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Soon Kieng Phua
- Department of Pathology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore
| | - Adrian F Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Mark Yan-Yee Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore; National University Heart Centre, National University Health System, 119074, Singapore
| | - Gerald F Watts
- School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, WA, 6009, Australia; Department of Cardiology, Royal Perth Hospital, Western Australia, Victoria Square, Perth, WA, 6000, Australia
| | - Chew-Kiat Heng
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 12, 119228, Singapore; Khoo Teck Puat - National University Children's Medical Institute, National University Health System, 5 Lower Kent Ridge Road, 119074, Singapore
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21
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Tan YK, Kwan YH, Teo DCL, Velema M, Deinum J, Tan PT, Zhang M, Khoo JJC, Loh WJ, Gani L, King TFJ, Tan EJH, Soh SB, Au VSC, Tay TL, Dacay LMQ, Ng KS, Wong KM, Wong ASY, Ng FC, Aw TC, Chan YHB, Tong KL, Lee SSG, Chai SC, Puar THK. Improvement in quality of life and psychological symptoms after treatment for primary aldosteronism: Asian Cohort Study. Endocr Connect 2021; 10:834-844. [PMID: 34223820 PMCID: PMC8346187 DOI: 10.1530/ec-21-0125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND In addition to increased cardiovascular risk, patients with primary aldosteronism (PA) also suffer from impaired health-related quality of life (HRQoL) and psychological symptoms. We assessed for changes in HRQoL and depressive symptoms in a cohort of Asian patients with PA, after surgical and medical therapy. METHODS Thirty-four patients with PA were prospectively recruited and completed questionnaires from 2017 to 2020. HRQoL was assessed using RAND-36 and EQ-5D-3L, and depressive symptoms were assessed using Beck Depression Inventory (BDI-II) at baseline, 6 months, and 1 year post-treatment. RESULTS At 1 year post-treatment, significant improvement was observed in both physical and mental summative scores of RAND-36, +3.65, P = 0.023, and +3.41, P = 0.033, respectively, as well as four subscale domains (physical functioning, bodily pain, role emotional, and mental health). Significant improvement was also seen in EQ-5D dimension of anxiety/depression at 1 year post-treatment. Patients treated with surgery (n = 21) had significant improvement in EQ-5D index score post-treatment and better EQ-5D outcomes compared to the medical group (n = 13) at 1 year post-treatment. 37.9, 41.6 and 58.6% of patients had symptoms in the cognitive, affective and somatic domains of BDI-II, respectively. There was a significant improvement in the affective domain of BDI-II at 1 year post-treatment. CONCLUSION Both surgical and medical therapy improve HRQoL and psychological symptoms in patients with PA, with surgery providing better outcomes. This highlights the importance of early diagnosis, accurate subtyping and appropriate treatment of PA.
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Affiliation(s)
- Yen Kheng Tan
- Duke-NUS Medical School, SingHealth, Singapore, Singapore
| | - Yu Heng Kwan
- Department of Internal Medicine, Singapore General Hospital, Singapore, Singapore
| | | | - Marieke Velema
- Division of Endocrinology, Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jaap Deinum
- Division of Vascular Medicine, Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pei Ting Tan
- Department of Clinical Trials Research Unit, Changi General Hospital, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Linsey Gani
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Thomas F J King
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Eberta Jun Hui Tan
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Shui Boon Soh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Keng Sin Ng
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | - Kang Min Wong
- Department of Diagnostic Radiology, Changi General Hospital, Singapore, Singapore
| | | | - Foo Cheong Ng
- Department of Urology, Changi General Hospital, Singapore, Singapore
| | - Tar Choon Aw
- Department of Laboratory Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | | | - Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Troy Hai Kiat Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
- Correspondence should be addressed to T H K Puar:
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22
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Chan YHB, Loh LM, Foo RS, Loh WJ, Lim DST, Zhang M, Sultana R, Tan YK, Ng KS, Tay D, Swee DS, Au V, Tay TL, Khoo J, Zhu L, Lee L, Tan SY, Kek PC, Puar TH. Re-evaluating absent clinical success after adrenalectomy in unilateral primary aldosteronism. Surgery 2021; 170:1389-1396. [PMID: 34183182 DOI: 10.1016/j.surg.2021.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/03/2021] [Accepted: 05/20/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Adrenalectomy cures unilateral primary aldosteronism, and it improves or cures hypertension. However, a significant proportion of patients are classified with absent clinical success postsurgery, suggesting that surgery was ineffective. METHODS We assessed all patients 6 to 12 months post-surgery for clinical outcomes using Primary Aldosteronism Surgical Outcomes (PASO), AVIS-2, and CONNsortium criteria. We estimated blood pressure changes after adjustment for changes in defined daily dosages of antihypertensive medications. We also reassessed all patients using PASO at their recent clinical visit. RESULTS A total of 104 patients with unilateral primary aldosteronism underwent adrenalectomy at 2 tertiary centers from 2000 to 2019; 24 (23%), 31 (30%), and 54 (52%) patients were classified with absent clinical success using PASO, AVIS-2, and CONNsortium criteria, respectively. Among 24 patients with absent clinical success using PASO criteria, 10 had complete biochemical cure, 3 partial, 2 absent, and 9 had resolution of hypokalemia. On multivariable analysis, absent clinical success was associated with presence of hyperlipidemia, diabetes mellitus, and lower defined daily dosages at baseline. After adjustment for changes in defined daily dosages, 7 of 24 patients showed blood pressure improvement ≥20/10 mm Hg post-surgery. After a follow-up of mean 5.6 years, 12 of 24 patients showed partial or complete clinical success when reassessed using PASO criteria. Only 6 of 104 (5.8%) patients failed to show clinical improvement post-surgery using any of the 3 mentioned criteria or using PASO criteria at their recent clinical visit. CONCLUSION Although some patients may be classified with absent clinical success post-surgery, the assessment of clinical outcomes remains subject to many variables. In patients with unilateral primary aldosteronism, evidenced by lateralization on AVS, unilateral adrenalectomy should remain the recommended treatment.
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Affiliation(s)
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Roger S Foo
- Cardiovascular Research Institute, Centre for Translational Medicine, MD6, National University Health System, Singapore; Genome Institute of Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Dawn S T Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Meifen Zhang
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | | | | | - Keng Sin Ng
- Department of Radiology, Changi General Hospital, SingHealth, Singapore; Department of Radiology, Mt Alvernia Hospital, Singapore
| | - Donovan Tay
- Department of Endocrinology, Sengkang General Hospital, SingHealth, Singapore
| | - Du Soon Swee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Vanessa Au
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Tunn Lin Tay
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Ling Zhu
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Lynette Lee
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore; Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Sarah Y Tan
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore; Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore.
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23
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Loh WJ, Dacay LM, Tan CSH, Ang SF, Yap F, Lim SC, Khoo J. Glucokinase activating mutation causing hypoglycaemia diagnosed late in adult who fasts for Ramadhan. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210043. [PMID: 34184638 PMCID: PMC8240715 DOI: 10.1530/edm-21-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Activating mutation of glucokinase gene (GCK) causes resetting of insulin inhibition at a lower glucose threshold causing hyperinsulinaemic hypoglycaemia (GCK-HH). This is the first reported case who tolerated years of regular fasting during Ramadhan, presenting only with seizure and syncope now. We describe a case with GCK gene variant p.T65I diagnosed in a 51-year-old woman with hypoglycaemia unawareness even at glucose level of 1.6 mmol/L. Insulin and C-peptide levels during hypoglycaemia were suggestive of hyperinsulinism, but at a day after intravenous glucagon, hypoglycaemia occurred with low insulin and C-peptide levels, pointing against insulinoma as the underlying aetiology. Imaging studies of the pancreas and calcium arterial stimulation venous sampling were unremarkable. A review of old medical records revealed asymptomatic hypoglycaemia years ago. Genetic testing confirmed activating mutation of GCK. Hypoglycaemia was successfully controlled with a somatostatin analogue. This case highlights the importance of consideration of genetic causes of hypoglycaemia in adulthood, especially when imaging is uninformative. LEARNING POINTS Consider genetic causes of endogenous hyperinsulinism hypoglycaemia in adulthood, especially when imaging is uninformative. Late presentation of activating mutation of GCK can occur because of hypoglycaemia unawareness. Long-acting somatostatin analogue may be useful for the treatment of activating mutation of GCK causing hypoglycaemia. Depending on the glucose level when the blood was taken, and the threshold of glucose-stimulated insulin release (GSIR), the serum insulin and C-peptide levels may be raised (hyperinsulinaemic) or low (hypoinsulinaemic) in patients with activating mutation of GCK. Glucagon may be useful to hasten the process of unmasking the low insulin level during hypoglycaemia below the GSIR level of which insulin released is suppressed.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Clara Si Hua Tan
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fabian Yap
- Department of Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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24
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Abstract
Abstract
Introduction: Patients with primary aldosteronism (PA) have increased cardiovascular risk and studies have found that medical therapy fails to ameliorate this. This may be due to side effects and limited efficacy of medications at tolerable doses. Methods: We conducted a retrospective study on 201 patients with PA treated with medical therapy (spironolactone, eplerenone or amiloride) for PA from 2000–2020 at two tertiary centres. Patients were assessed for efficacy to achieve clinical and biochemical control, and for side effects. Results: 53.7% of patients achieved blood pressure <140/90mmHg, 44.6% achieved serum potassium ≥4.3mmol/L, and 63.2% achieved renin levels >1ng/ml/hr. Concordance between biochemical control as assessed by potassium and renin levels was 49%. 45.3% of patients experienced side effects, with 8.5% switching to another medication, 18.9% decreasing dose, and 10.0% stopping medications altogether. Risk factors for side effects were spironolactone use, dose ≥50mg, duration of treatment ≥1 year, male gender and unilateral PA. Patients with unilateral PA, compared to bilateral PA, used higher median doses of spironolactone, 75mg vs 50mg, P<0.001, but more had persistent hypokalemia, 20.5% versus 6.4%, P=0.007. 44 patients with unilateral PA underwent surgery after initial medical therapy, which further improved systolic and diastolic BP, from 142 to 134mmHg, P<0.001, and from 85 to 79mmHg, P<0.001, respectively. Conclusion: Dose-dependent side effects limit the efficacy of medical therapy in PA. Future prospective studies should assess the best monitoring strategy for biochemical control during long-term medical therapy. In patients with unilateral PA, surgery remains a better option compared to life-long medications.
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Affiliation(s)
- Troy Puar
- Changi General Hospital, Singapore, Singapore
| | | | - Lih-Ming Loh
- Singapore General Hospital, Singapore, Singapore
| | - Roger Foo
- National University Health System, Singapore, Singapore
| | | | - Joan Khoo
- Changi General Hospital, Singapore, Singapore
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25
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Tee LY, Alhamid SM, Tan JL, Oo TD, Chien J, Galinato P, Tan SY, Humaira S, Fong RKC, Puar TH, Loh WJ, Santosa A, Khoo J, Rosario BH. COVID-19 and Undiagnosed Pre-diabetes or Diabetes Mellitus Among International Migrant Workers in Singapore. Front Public Health 2020; 8:584249. [PMID: 33262970 PMCID: PMC7686043 DOI: 10.3389/fpubh.2020.584249] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/22/2020] [Indexed: 01/15/2023] Open
Abstract
Objective: Migrant workers, a marginalized and under-resourced population, are vulnerable to coronavirus disease 2019 (COVID-19) due to limited healthcare access. Moreover, metabolic diseases—such as diabetes mellitus (DM), hypertension, and hyperlipidemia—predispose to severe complications and mortality from COVID-19. We investigate the prevalence and consequences of undiagnosed metabolic illnesses, particularly DM and pre-diabetes, in international migrant workers with COVID-19. Methods: In this retrospective analysis, we analyzed the medical records of international migrant workers with laboratory-confirmed COVID-19 hospitalized at a tertiary hospital in Singapore from April 21 to June 1, 2020. We determined the prevalence of DM and pre-diabetes, and analyzed the risk of developing complications, such as pneumonia and electrolyte abnormalities, based on age and diagnosis of DM, and pre-diabetes. Results: Two hundred and fouty male migrant workers, with mean age of 44.2 years [standard deviation (SD), 8.5years], were included. Twenty one patients (8.8%) were diagnosed with pre-diabetes, and 19 (7.9%) with DM. DM was poorly controlled with a mean HbA1c of 9.9% (SD, 2.4%). 73.7% of the patients with DM and all the patients with pre-diabetes were previously undiagnosed. Pre-diabetes was associated with higher risk of pneumonia [odds ratio (OR), 10.8, 95% confidence interval (CI), 3.65–32.1; P < 0.0001], hyponatremia (OR, 8.83; 95% CI, 1.17–66.6; P = 0.0342), and hypokalemia (OR, 4.58; 95% CI, 1.52–13.82; P = 0.0069). Moreover, patients with DM or pre-diabetes developed COVID-19 infection with lower viral RNA levels. Conclusions: The high prevalence of undiagnosed pre-diabetes among international migrant workers increases their risk of pneumonia and electrolyte abnormalities from COVID-19.
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Affiliation(s)
- Louis Y Tee
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | | | - Jeriel L Tan
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Theik Di Oo
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Jaime Chien
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Primavera Galinato
- Department of Geriatric Medicine, Changi General Hospital, Singapore, Singapore
| | - Seow Yen Tan
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | - Shafi Humaira
- Department of Infectious Diseases, Changi General Hospital, Singapore, Singapore
| | | | - Troy H Puar
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Anindita Santosa
- Department of Rheumatology, Changi General Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
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26
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Chua TH, Loh WJ. Osmotic demyelination syndrome in a patient with Noonan syndrome and anterior hypopituitarism. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200039. [PMID: 32820141 PMCID: PMC7487176 DOI: 10.1530/edm-20-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
SUMMARY Severe hyponatremia and osmotic demyelination syndrome (ODS) are opposite ends of a spectrum of emergency disorders related to sodium concentrations. Management of severe hyponatremia is challenging because of the difficulty in balancing the risk of overcorrection leading to ODS as well as under-correction causing cerebral oedema, particularly in a patient with chronic hypocortisolism and hypothyroidism. We report a case of a patient with Noonan syndrome and untreated anterior hypopituitarism who presented with symptomatic hyponatremia and developed transient ODS. LEARNING POINTS Patients with severe anterior hypopituitarism with severe hyponatremia are susceptible to the rapid rise of sodium level with a small amount of fluid and hydrocortisone. These patients with chronic anterior hypopituitarism are at high risk of developing ODS and therefore, care should be taken to avoid a rise of more than 4-6 mmol/L per day. Early recognition and rescue desmopressin and i.v. dextrose 5% fluids to reduce serum sodium concentration may be helpful in treating acute ODS.
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Affiliation(s)
- Tzy Harn Chua
- Department of Endocrinology, Changi General Hospital, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore
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27
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Affiliation(s)
- Kangqi Ng
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Beng Hoong Poon
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Troy Hai Kiat Puar
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jessica Li Shan Quah
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Wann Jia Loh
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Yu Jun Wong
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Thean Yen Tan
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
| | - Jagadesan Raghuram
- Changi General Hospital, Singapore (K.N., B.H.P., T.H.K., J.L.S., W.J.L., Y.J.W., T.Y.T., J.R.)
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28
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Puar T, Loh WJ, Lim DST, Zhang M, Foo RS, Lee L, Khoo JJC, Tay D, Dekkers T, Velema MS, Deinum J, Kek PC. SAT-547 Aldosterone-Potassium Ratio Predicts Primary Aldosteronism Subtype. J Endocr Soc 2020. [PMCID: PMC7208901 DOI: 10.1210/jendso/bvaa046.574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Prediction models have been developed to predict either unilateral or bilateral primary aldosteronism, and these have not been validated externally. We aimed to develop a simplified score to predict both subtypes and validate this externally. Methods Our development cohort was taken from 165 patients who underwent adrenal vein sampling (AVS) in two Asian tertiary centres. Unilateral disease was determined using both AVS and post-operative outcome. Multivariable analysis was used to construct prediction models. We validated our tool in a European cohort of 97 patients enrolled in a clinical trial. Previously published prediction models were also tested in our cohorts. Results Backward stepwise logistic regression analysis yielded a final tool using baseline-aldosterone-to-lowest-potassium ratio (APR, ng/dL/mmol/L), with an area under receiver operating characteristic curve of 0.80 (95% CI: 0.70 - 0.89). In the Asian development cohort, probability of bilateral disease was 90.0% (with APR <5) and probability of unilateral disease was 91.4% (with APR >15). Similar results were seen in the European validation cohort. Combining both cohorts, probability of bilateral disease was 76.7% (with APR <5), and probability for unilateral was 91.7% (with APR >15). Other models had similar predictive ability but required more variables, and were less sensitive for identifying bilateral PA. Conclusion The novel aldosterone-potassium ratio (APR) is a convenient score to guide clinicians and patients of various ethnicities on the probability of PA subtype. Using APR to identify patients more likely to benefit from AVS may be a cost-effective strategy to manage this common condition.
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Affiliation(s)
- Troy Puar
- Changi General Hospital, Singapore, Singapore
| | | | | | | | - Roger S Foo
- National University Health System, Singapore, Singapore
| | - Lynette Lee
- Singapore General Hospital, Singhealth, Singapore, Singapore
| | | | - Donovan Tay
- Sengkang General Hospital, Singapore, Singapore
| | - Tanja Dekkers
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - Jaap Deinum
- Radboud Univ Nijmegen, Nijmegen, Netherlands
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29
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Loh WJ, Stevenson JC, Godsland IF. Independent relationships between bone mineral density, regional body fat and insulin sensitivity in white males. Clin Endocrinol (Oxf) 2019; 91:63-71. [PMID: 30973644 DOI: 10.1111/cen.13989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 03/16/2019] [Accepted: 04/09/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Adiposity and insulin sensitivity may affect bone mineral density (BMD), but the confounding effect of weight hinders discrimination of independent associations. We explored whether regional fat masses and insulin sensitivity are independently related to BMD. MATERIALS AND METHODS Relationships between total and regional body fat, insulin sensitivity and measures of BMD in 8 different regions were evaluated in a cross section of 590 generally healthy, white males, 274 of whom received measurement of insulin sensitivity (Si) using the intravenous glucose tolerance test. Measurements included total, android and gynoid fat and lean body mass and regional BMDs by dual-energy X-ray absorptiometry. Linear regression analyses were combined in a mediation analysis to explore associations with each regional BMD. RESULTS Weight correlated positively with total fat mass (R2 = 0.67, P < 0.001) and negatively with Si (R2 = 0.14, P < 0.001). Body composition measures were consistently positively related to BMD in all regions except lumbar and thoracic spine. Accounting for body weight rendered negative majority of associations between total and regional fat masses and BMDs. An independent association between android fat and spine BMD was particularly apparent. Si was positively associated with total and limb BMD (P < 0.01) specifically among exercisers. Accounting for Si diminished the associations of total fat (negative) and lean body mass (positive) with total and limb BMD. CONCLUSION Android fat is independently negatively associated with spine BMD. Among those taking exercise, increased insulin sensitivity is associated with higher limb BMD and may underlie positive associations between lean body mass and BMD.
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Affiliation(s)
- Wann Jia Loh
- Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, London, UK
- Department of Endocrinology, Changi General Hospital, Singapore
| | - John C Stevenson
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ian F Godsland
- Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, London, UK
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Loh WJ, Lim DST, Loh LM, Kek PC. Factors Associated with Resolution of Hypertension after Adrenalectomy in Patients with Primary Aldosteronism. Endocrinol Metab (Seoul) 2018; 33:355-363. [PMID: 30112867 PMCID: PMC6145965 DOI: 10.3803/enm.2018.33.3.355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/22/2018] [Accepted: 06/03/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the factors associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism. A secondary aim was to describe our use of the contralateral ratio in adrenal venous sampling (AVS) in the setting of suboptimal successful cannulation rates. METHODS A retrospective review of patients who underwent AVS followed by unilateral adrenalectomy for primary aldosteronism was performed. RESULTS Complete resolution of hypertension and hypokalemia was seen in 17 of 40 patients (42.5%), while a clinical improvement in hypertension was seen in 38 of 40 (95%). Shorter duration of hypertension, mean aldosteronoma resolution score (ARS), and a high ARS of 3 to 5 were associated with resolution of hypertension after adrenalectomy (P=0.02, P=0.02, and P=0.004, respectively). Of the individual components of ARS, only a duration of hypertension of ≤6 years was associated with resolution of hypertension after adrenalectomy (P=0.03). CONCLUSION A shorter duration of hypertension was significantly associated with resolution of hypertension after adrenalectomy in patients with primary aldosteronism.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore.
| | - Dawn Shao Ting Lim
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Lih Ming Loh
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, SingHealth, Singapore
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Loh WJ, Johnston DG, Oliver N, Godsland IF. Skinfold thickness measurements and mortality in white males during 27.7 years of follow-up. Int J Obes (Lond) 2018; 42:1939-1945. [PMID: 29491491 DOI: 10.1038/s41366-018-0034-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 12/23/2017] [Accepted: 01/03/2018] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Obesity is a major risk factor for mortality from a range of causes. We investigated whether skinfold measurements were associated with mortality independently of variation in body mass index (BMI). METHODS A prospective analysis of mortality in 870 apparently healthy adult Caucasian men participating in an occupational health cohort was undertaken. At baseline, skinfold measurements were taken at biceps, triceps, iliac and subscapular sites. Derived measurements included the sum of all four skinfolds and subscapular to triceps, subscapular to iliac and BMI to iliac ratios. All-cause mortality was analysed by Cox proportional hazards modelling and death in specific mortality subcategories by competing risks analysis. RESULTS During a mean of 27.7 years follow up, there were 303 deaths (119 cancer, 101 arteriovascular, 40 infection, 43 other). In univariable analysis, BMI was associated with all-cause, cancer, arteriovascular and other mortality and subscapular skinfold with all-cause and arteriovascular mortality. On bivariable analysis, with inclusion of BMI, subscapular skinfold ceased to be a associated with mortality but iliac skinfold emerged as strongly, negatively associated with all-cause and arteriovascular mortality. In multivariable analysis, with inclusion of age, BMI, smoking, alcohol and exercise, iliac skinfold was negatively associated with all-cause (Hazard ratio HR 0.77, 95% confidence interval CI 0.66-0.90, p = 0.002), arteriovascular (HR 0.75, 95%CI 0.58,0.97, p = 0.02) and infection (HR 0.63, 95%CI 0.42,0.94, p = 0.02) death. Among obese participants (BMI ≥ 30 kg/m2), iliac skinfold of ≤9.7 mm was associated with a six-fold increase in all-cause mortality risk. CONCLUSION Low iliac skinfold thickness is an independent risk factor for all-cause mortality in adult white males with risk apparently concentrated among people who are obese.
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Affiliation(s)
- Wann Jia Loh
- Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St. Mary's Campus, London, UK. .,Department of Endocrinology, Changi General Hospital, Singapore, Singapore.
| | - Desmond G Johnston
- Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St. Mary's Campus, London, UK
| | - Nick Oliver
- Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St. Mary's Campus, London, UK
| | - Ian F Godsland
- Diabetes Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College London, St. Mary's Campus, London, UK
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Tay WL, Loh WJ, Lee LAL, Chng CL. Persistent hyperthyroidism and de novo Graves' ophthalmopathy after total thyroidectomy. Endocrinol Diabetes Metab Case Rep 2017; 2017:EDM170109. [PMID: 29062485 PMCID: PMC5640566 DOI: 10.1530/edm-17-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/25/2017] [Indexed: 11/08/2022] Open
Abstract
We report a patient with Graves' disease who remained persistently hyperthyroid after a total thyroidectomy and also developed de novo Graves' ophthalmopathy 5 months after surgery. She was subsequently found to have a mature cystic teratoma containing struma ovarii after undergoing a total hysterectomy and salpingo-oophorectomy for an incidental ovarian lesion. LEARNING POINTS It is important to investigate for other causes of primary hyperthyroidism when thyrotoxicosis persists after total thyroidectomy.TSH receptor antibody may persist after total thyroidectomy and may potentially contribute to the development of de novo Graves' ophthalmopathy.
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Affiliation(s)
- Wei Lin Tay
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | | | - Chiaw Ling Chng
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
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Loh WJ, Yu Y, Loo CM, Low SY. Factors associated with mortality among patients with active pulmonary tuberculosis requiring intensive care. Singapore Med J 2016; 58:656-659. [PMID: 27653545 DOI: 10.11622/smedj.2016160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The aim of this study was to identify patient characteristics and risk factors associated with in-hospital mortality of patients with pulmonary tuberculosis (PTB) requiring intensive care unit (ICU) management. METHODS A retrospective chart review was conducted of all patients with active PTB admitted to the ICU at Singapore General Hospital, Singapore, between January 2005 and December 2010. RESULTS There were 2,155 patients with active PTB diagnosed, of whom 83 (3.9%) patients were admitted to the ICU, but eight were excluded because their admission to the ICU was unrelated to PTB. The most common comorbidities were diabetes mellitus (n = 23, 30.7%) and immunocompromised host (n = 25, 33.3%). A few (n = 4, 5.3%) of the patients had HIV coinfection. A majority (n = 67, 89.3%) of patients required mechanical ventilation and the mean duration of mechanical ventilation was 8.05 ± 14.43 days. Mean duration of ICU stay and hospital stay were 10.23 ± 15.8 days and 33.7 ± 50.7 days, respectively. In-hospital mortality was 62.7% (n = 47), and 36 of these patients died while in the ICU (ICU mortality, 48.0%). Univariate analysis identified ischaemic heart disease, low albumin, Acute Physiology and Chronic Health Evaluation score, disseminated intravascular coagulation, shock and multiorgan failure as significantly associated with mortality. Multivariate analysis showed that low albumin on the day of ICU admission was the only significant independent predictor of death (p = 0.033). CONCLUSION In-hospital mortality from active PTB requiring ICU admission was 62.7%, and low albumin was an independent predictor of mortality in this study.
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Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Yue Yu
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| | - Su Ying Low
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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Peh WM, Loh WJ, Phua GC, Loo CM. Eliminating guidewire retention during ultrasound guided central venous catheter insertion via an educational program, a modified CVC set, and a drape with reminder stickers. BMJ Qual Improv Rep 2016; 5:bmjquality_uu209550.w3941. [PMID: 27493743 PMCID: PMC4949605 DOI: 10.1136/bmjquality.u209550.w3941] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 12/10/2015] [Indexed: 11/04/2022]
Abstract
Guidewire retention is a severe but preventable complication from central venous catheter (CVC) insertion. There were three cases of guidewire retention during CVC insertion in the medical intensive care unit (MICU) in Singapore General Hospital, in the period between December 2011 and February 2012. The primary objective of this quality improvement project was to eliminate future incidences of guidewire retention during CVC insertion in the MICU and medical intermediate care area (MICA) via a structured educational program and a cost effective modified CVC set. The secondary objective was to perform a cost analysis and comparison between the use of the conventional hospital CVC set and drape with our newly modified CVC dressing kit. Root cause analysis of the three cases identified major factors leading to guidewire retention. Interventions were planned and tested using PDSA cycles. Internal medicine trainees rotating through MICU and MICA during the period between February 2012 and June 2013 underwent a multi-modal structured CVC insertion training program with hands on simulation. They also used a newly modified CVC dressing kit and drape. The CVC dressing kit was modified (CVC PLUS) to include a sterile drape with reminder stickers stating "REMOVE the GUIDEWIRE," as well as a sterile ultrasound sleeve. The total number of CVC insertions performed and guidewire retentions were monitored. During the period of study there were 320 CVC insertions in the MICU and MICA. Since this quality improvement project was initiated, and up to the submission of this article, there have not been any further cases of guidewire retention in the MICU and MICA. The total cost reduction per use of CVC PLUS was S$29.26 (Singaporean Dollars). A multi-modal structured training program, integrated with a modified, pre-packed CVC set, and drapes with reminder stickers (all included in CVC PLUS) were cost effective, and improved patient safety by eliminating guidewire retention during CVC insertion.
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Loh WJ, Sittampalam K, Tan SC, Chandran M. Symptomatic empty sella syndrome: an unusual manifestation of Erdheim-Chester disease. Endocrinol Diabetes Metab Case Rep 2015; 2015:140122. [PMID: 25810917 PMCID: PMC4372670 DOI: 10.1530/edm-14-0122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 03/10/2015] [Indexed: 11/08/2022] Open
Abstract
UNLABELLED Erdheim-Chester disease (ECD) is a potentially fatal condition characterized by infiltration of multiple organs by non-Langerhans histiocytes. Although endocrine dysfunction has been reported in association with ECD, to date, there have been no previous reports of empty sella syndrome (ESS) associated with it. We report the case of a patient with ECD who had symptomatic ESS. A 55-year-old man of Chinese ethnicity initially presented with symptoms of heart failure, fatigue and knee joint pain. Physical examination revealed xanthelasma, gynaecomastia, lung crepitations, hepatomegaly and diminished testicular volumes. He had laboratory evidence of hypogonadotrophic hypogonadism, secondary hypoadrenalism and GH deficiency. Imaging studies showed diffuse osteosclerosis of the long bones on X-ray, a mass in the right atrium and thickening of the pleura and of the thoracic aorta on fusion positron emission tomography-computed tomography. Magnetic resonance imaging (MRI) of the brain showed an empty sella. The diagnosis of ECD was confirmed by bone biopsy. LEARNING POINTS ECD is a multisystemic disease that can affect the pituitary and other organs. The diagnosis of ECD is based on clinical and radiological features and histology, showing lipid-laden CD68(+) CD1a(-) S100(-) histiocytes surrounded by fibrosis.The finding of xanthelasmas especially in the presence of normal lipid levels in the presence of a multisystem infiltrative disorder should raise the suspicion of ECD.Systemic perturbation of autoimmunity may play a role in the pathogenesis of ECD and is an area that merits further research.
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Affiliation(s)
- Wann Jia Loh
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital , Academia, 20, College Road, Singapore, 169856 , Singapore
| | - Kesavan Sittampalam
- Department of Pathology, Singapore General Hospital , Academia, 20, College Road, Singapore, 169856 , Singapore
| | - Suan Cheng Tan
- Department of Radiology, Singapore General Hospital , Academia, 20, College Road, Singapore, 169856 , Singapore
| | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital , Academia, 20, College Road, Singapore, 169856 , Singapore
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Loh WJ, Yu Y, Loo CM, Low SY. Characteristics and Outcomes of Patients With Active Pulmonary Tuberculosis Requiring Intensive Care. Chest 2014. [DOI: 10.1378/chest.1822171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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