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Fulltext Co-Occurrence of Exogenous and Endogenous Cushing's Syndromes-Dilemma in Diagnosis

Tong CV, Rajoo S

Case Rep Endocrinol, 2019;2019:2986312.
PMID: 31737375 DOI: 10.1155/2019/2986312

Approach to patients who manifest with features of Cushing's syndrome often begin with exclusion of exposure to excessive exogenous source of glucocorticoids (GC). Most guidelines advocate no further assessment if excessive exogenous GC use is present. We present a case of a 66-year-old lady who was noted to have typical features of Cushing's syndrome. As she gave a very clear history of ingesting exogenous GC for a year, no further work up was undertaken. Despite cessation of GC for a year, she continued to have thin skin and easy bruising. Upon admission for hypertensive emergency, her clinician took note of her changes and investigated her for endogenous Cushing's syndrome. Her cortisol post overnight dexamethasone suppression test was 707 nmol/l. Post low dose dexamethasone suppression test yielded a cortisol of 1133.2 nmol/l. 24 hours urine cortisol was 432.2 nmol/l. Plasma ACTH was 1.1 pmol/l, indicating an ACTH independent Cushing's syndrome. We proceeded with Computed tomography scan (CT scan) of adrenals which revealed a right adrenal adenoma measuring 4.4 × 3.4 × 4.0 cm. Right retroperiteneoscopic adrenalectomy was done. Histopathology examination was consistent with adrenal cortical adenoma with foci of myelolipoma. Post adrenalectomy she developed hypocortisolism secondary to contralateral adrenal suppression which lasted up to the present date. Her cutaneous and musculoskeletal manifestations improved substantially. Co-occurrence of endogenous and exogenous Cushing's syndromes is uncommon but should be considered in patients whose Cushingnoid features do not resolve after cessation of exogenous GC.
Fulltext Waste heat recovery research - a systematic bibliometric analysis (1991 to 2020)

Kuah CT, Koh QY, Rajoo S, Wong KY

Environ Sci Pollut Res Int, 2023 Jun;30(28):72074-72100.
PMID: 35716302 DOI: 10.1007/s11356-022-21377-6

Human usage of non-renewable energy resources has caused many environmental issues, which include air pollution, global warming, and climate irregularities. To counter these issues, researchers have been seeking after alternative renewable energy sources and ways to manage energy more efficiently. This is where energy recovery technologies such as waste heat recovery (WHR) come into play. WHR is a form of waste to energy conversion. Waste heat can be captured and converted into usable energy instead of dumping it into the environment. In the more recent years, the WHR research field has gained great attention in the scientific community as well as in some energy-intensive industries. This article presents a bibliometric overview of the academic research on WHR over the span of 30 years from 1991 to 2020. A total of 5682 documents from Web of Science (WoS) have been retrieved and analyzed using various bibliometric methods, including performance analysis and network analysis. The analyses were performed on different actors in the field, i.e., funding agencies, journals, authors, organizations, and countries. In addition, several network mappings were done based on co-citation, co-authorship, and co-occurrences of keywords analyses. The research identified the most productive and influential actors in the field, established and emergent research topics, as well as the interrelations and collaboration patterns between different actors. The findings can be a robust roadmap for further research in this field.
Fulltext Unusual presentation of lung carcinoma with pituitary metastasis: a challenging diagnosis and sodium management dilemmas

Wong PS, Rajoo S, Achmad Sankala H, Long Bidin MB

Endocr Oncol, 2022 Jan;2(1):K15-K20.
PMID: 37435455 DOI: 10.1530/EO-22-0064

SUMMARY: Pituitary metastasis (PM) is a rare complication of an advanced malignancy. Albeit rare, PM can be more detected and achieve a longer survival rate through frequent neuroimaging and newer oncology therapies. Lung cancer is the most frequent primary site, followed by breast and kidney cancers. Patients with lung cancer generally present with respiratory symptoms and are commonly diagnosed at an advanced stage already. Nevertheless, physicians should be mindful of other systemic manifestations as well as signs and symptoms related to metastatic spread and paraneoplastic syndromes. Herein, we report the case of a 53-year-old woman who presented with PM as the first sign of an undiagnosed lung cancer. Initially, her condition was a challenging diagnosis and was even complicated with diabetes insipidus (DI), which can present as severe hyponatremia when coexisting with adrenal insufficiency. This case also highlights that treating DI with antidiuretic hormone (ADH) replacement was complicated by extreme difficulties in attaining satisfactory sodium and water balance during the clinical course, with the possibility of coexistent DI and syndrome of inappropriate ADH secretion because of the underlying lung cancer.
LEARNING POINTS: When patients present with pituitary mass and diabetes insipidus (DI), pituitary metastasis should be considered as an initial differential diagnosis. DI caused by pituitary adenoma is rare and is typically a late finding.DI can present as severe hyponatremia when coexisting with adrenal insufficiency.Cortisol can directly inhibit endogenous antidiuretic hormone (ADH) secretion. Patients with adrenocorticotropic hormone deficiency will have increased tonic ADH activity and subsequently reduced capacity for free-water excretion. However, when on steroid therapy, patients should be monitored for possible DI because steroids can restore free-water excretion.A substantial change in serum sodium after desmopressin treatment should eliminate the possibility of desmopressin overdose or coexistence of DI and syndrome of inappropriate ADH secretion in patients with lung cancer. Therefore, frequent monitoring of serum sodium concentrations is crucial.
Fulltext Cryptorchidism is a Useful Clue for Idiopathic Hypogonadotropic Hypogonadism in Pituitary Stalk Thickening

Nagaratnam S, Rajoo S, Bidin MBL, Zain NRM

J ASEAN Fed Endocr Soc, 2021;36(1):95-97.
PMID: 34177095 DOI: 10.15605/jafes.036.01.09

Pituitary stalk lesions can represent a wide range of pathologies. The exact cause is often unknown due to hesitancy to proceed with biopsy. We present a 16-year-old adolescent who presented with delayed puberty, short stature and bilateral cryptorchidism. He was found to have a thickened pituitary stalk of uncertain etiology with partial hypopituitarism (gonadotrophin and growth hormone deficiency) on further assessment. The presence of bilateral cryptorchidism and micropenis represents lack of "mini puberty," a phenomenon of activation of the hypothalamic-pituitary-gonadal (HPG) axis in-utero or within the first few months of life.1 These key clinical features have been useful to establish an early temporal relationship and suggest a congenital origin of disease. This enabled a more conservative approach of surveillance to be employed as opposed to invasive pathological examination with pituitary stalk biopsy.
Fulltext Rare Case of Large Catecholamine Secreting Ganglioneuroma in an Asymptomatic Elderly Male

Soundarajan T, Bidin MBL, Rajoo S, Yunus R

J ASEAN Fed Endocr Soc, 2022;37(1):87-90.
PMID: 35800596 DOI: 10.15605/jafes.037.01.10

Ganglioneuromas (GNs) are benign tumors that originate from neural crest cells, composed mainly of mature ganglion cells. These tumors, which are usually hormonally silent, tend to be discovered incidentally on imaging tests and occur along the paravertebral sympathetic chain, from the neck to the pelvis and occasionally in the adrenal medulla. Rarely, GNs secrete catecholamines.1 Adrenal GNs occur most frequently in the fourth and fifth decades of life, whereas GNs of the retroperitoneum and posterior mediastinum are usually encountered in younger adults.2 Adrenal GNs are commonly hormonally silent and asymptomatic; even when the lesion is of substantial size.3 We report an incidentally detected asymptomatic case of an adrenal ganglioneuroma with mildly elevated urinary catecholamine levels in an elderly male. After preoperative alpha blockade, the patient underwent open right adrenalectomy. Upon microscopic examination, the right adrenal mass proved to be a ganglioneuroma, maturing type and the immunohistochemistry examination showed immunoreactivity to synaptophysin, chromogranin, and CD 56, while S100 was strongly positive at the Schwannian stroma. Following resection, catecholamine levels normalized, confirming the resected right adrenal ganglioneuroma as the source of the catecholamine excess. This case represents a rare presentation of catecholamine-secreting adrenal ganglioneuroma in the elderly.
Switching from sulphonylurea to a sodium-glucose cotransporter2 inhibitor in the fasting month of Ramadan is associated with a reduction in hypoglycaemia

Wan Seman WJ, Kori N, Rajoo S, Othman H, Mohd Noor N, Wahab NA, et al.

Diabetes Obes Metab, 2016 06;18(6):628-32.
PMID: 26889911 DOI: 10.1111/dom.12649

The aim of the present study was to assess the hypoglycaemia risk and safety of dapagliflozin compared with sulphonylurea during the fasting month of Ramadan. In this 12-week, randomized, open-label, two-arm parallel group study, 110 patients with type 2 diabetes who were receiving sulphonylurea and metformin were randomized either to receive 10 mg (n = 58) of dapagliflozin daily or to continue receiving sulphonylurea (n = 52). The primary outcome was to compare the effects of dapagliflozin and sulphonylurea on the proportions of patients with at least one episode of hypoglycaemia during Ramadan, as well as to assess the safety of dapagliflozin when used to treat patients observing Ramadan. A lower proportion of patients had reported or documented hypoglycaemia in the dapagliflozin group than in the sulphonylurea group: 4 (6.9%) versus 15 (28.8%); p = 0.002. The relative risk of any reported or documented hypoglycaemia in the 4th week of Ramadan was significantly lower in the dapagliflozin group: RR=0.24, 95%CI: 0.09, 0.68; p=0.002. No significance differences were observed between the two groups regarding postural hypotension (13.8 vs 3.8%; p = 0.210) or urinary tract infections (10.3 vs 3.8%; p = 0.277). In conclusion, fewer patients exhibited hypoglycaemia in the dapagliflozin group than in the sulphonylurea group.
Recovery and utilisation of waste heat from flue/exhaust gases: a bibliometric analysis (2010-2022)

Nyakuma BB, Mahyon NI, Chiong MS, Rajoo S, Pesiridis A, Wong SL, et al.

Environ Sci Pollut Res Int, 2023 Aug;30(39):90522-90546.
PMID: 37479929 DOI: 10.1007/s11356-023-28791-4

The recovery and utilisation of waste heat from flue/exhaust gases (RU/WHFG) could potentially provide sustainable energy while curbing pollutant emissions. Over time, the RU/WHFG research landscape has gained significant traction and yielded innovative technologies, sustainable strategies, and publications. However, critical studies highlighting current advancements, publication trends, research hotspots, major stakeholders, and future research directions on RU/WHFG research remain lacking. Therefore, this paper presents a comprehensive bibliometric analysis and literature review of the RU/WHFG research landscape based on publications indexed in Scopus. Results showed that 123 publications and 2191 citations were recovered between 2010 and 2022. Publication trends revealed that the growing interest in RU/WHFG is mainly due to environmental concerns (e.g. pollution, global warming, and climate change), research collaborations, and funding availability. Stakeholder analysis revealed that numerous researchers, affiliations, and countries have actively contributed to the growth and development of RU/WHFG. Lin Fu and Tsinghua University (China) are the most prolific researchers and affiliations, whereas the National Natural Science Foundation of China (NSFC) and China are the most prolific funder and country, respectively. Funding availability from influential schemes such as NSFC has accounted for China's dominance. Keyword co-occurrence identified three major research hotspots, namely, thermal energy utilisation and management (cluster 1), integrated energy and resource recovery (cluster 2), and system analysis and optimisation (cluster 3). Literature review revealed that researchers are currently focused on maximising thermodynamic/energy efficiency, fuel minimisation, and emission reduction. Despite progress, research gaps remain in low-temperature/low-grade waste heat recovery, utilisation, storage, life cycle, and environmental impact analysis.
Fulltext Diabetes Insipidus Induced by Combination of Short-acting Octreotide and Lanreotide for Recurrent Carcinoid Crisis of Neuroendocrine Tumour: A Case Report

Guan GK, Rajoo S, Dusa NM, Yahya NHN, Bidin MBL

J ASEAN Fed Endocr Soc, 2021;36(2):220-222.
PMID: 34966210 DOI: 10.15605/jafes.036.02.09

Somatostatin analogue is useful in carcinoid crisis for symptom control. Optimal dosing of somatostatin analogues for carcinoid symptoms is not known. This case highlighted management issues using combination short-acting octreotide infusion with long-acting lanreotide during carcinoid crisis. The patient had left lung neuroendocrine tumour that metastasized to his liver and bone, post left lobectomy. Due to extensive metastasis to the liver causing recurrent carcinoid crisis, he required shorter interval long-acting lanreotide with continuous infusion of short-acting octreotide, which led to transient diabetes insipidus. Symptoms resolved with discontinuation of treatment. Somatostatin analogues, especially in combination, may inhibit the posterior pituitary resulting in diabetes insipidus. Prompt withdrawal of short-acting somatostatin analogue and initiation of desmopressin can reverse the complication. It is important to recognize this complication with combination of octreotide and lanreotide injections to avoid serious complications.
An integrated approach for a sustainable supplier selection based on Industry 4.0 concept

Fallahpour A, Wong KY, Rajoo S, Fathollahi-Fard AM, Antucheviciene J, Nayeri S

Environ Sci Pollut Res Int, 2021 Nov 18.
PMID: 34792774 DOI: 10.1007/s11356-021-17445-y

The recent advances in sustainable supply chain management are integrated with Industry 4.0 concepts. This study develops a new integrated model to consider the sustainability and Industry 4.0 criteria for the supplier selection management. The proposed approach consists of the fuzzy best worst method (FBWM) and the two-stage fuzzy inference system (FIS) to assess the selection of suppliers. Firstly, this study determines a comprehensive list of Industry 4.0 and sustainability criteria along with their definitions. Then, the importance weight of each criterion is computed by the FBWM. Subsequently, a two-stage FIS is devoted to nominate the suppliers' performance with regard to the sustainability and Industry 4.0 criteria. To show the applicability of our integrated model, a case study for a textile company in Iran is provided. Finally, some sensitivity analyses are done to assess the efficiency of the proposed integrated approach. One finding is to establish a decision-making framework to evaluate suppliers separately, rather than relatively in a fuzzy environment using Industry 4.0 and sustainability criteria.
Fulltext A Cross-sectional Study to Assess Beta-Cell Function in Individuals with Recently Diagnosed Young-Onset Type 2 Diabetes Mellitus and Its' Complications

Nagaratnam S, Rajoo S, Bidin MBL, Rahim NSC, Tharmathurai S, Arip M, et al.

J ASEAN Fed Endocr Soc, 2023;38(2):20-27.
PMID: 38045672 DOI: 10.15605/jafes.038.02.13

OBJECTIVE: The primary objective was to assess beta-cell function of recently-diagnosed young-onset type 2 diabetes mellitus (T2DM) individuals using basal and stimulated C-peptide levels. The secondary objective was to examine the association between C-peptide with metabolic factors and diabetes complications.
METHODOLOGY: A cross-sectional study was conducted for young-onset T2DM individuals aged 18-35 years with a disease duration of not more than 5 years. Plasma C-peptide was measured before and after intravenous glucagon injection. Demographic data, medical history and complications were obtained from medical records and clinical assessment. Continuous data were expressed as median and interquartile range (IQR). Categorical variables were described as frequency or percentage. Multivariable linear regression analysis was used to determine factors associated with C-peptide levels.
RESULTS: 113 participants with young-onset T2DM with a median (IQR) age of 29.0 (9.5) years and 24 (36) months were included in this study. The median (IQR) basal and stimulated C-peptide was 619 (655) pmol/L and 1231 (1024) pmol/L. Adequate beta-cell function was present in 78-86% of the participants based on the basal and stimulated C-peptide levels. We found hypertension, obesity and diabetic kidney disease (DKD) to be independently associated with higher C-peptide levels. In contrast, females, smokers, those on insulin therapy and with longer duration of disease had lower C-peptide levels.
CONCLUSION: Most recently diagnosed young-onset T2DM have adequate beta-cell function. Elevated C-peptide levels associated with obesity, hypertension and diabetic kidney disease suggest insulin resistance as the key driving factor for complications.

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