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BackgroundScreening for undiagnosed diabetes is not widely undertaken due to the high costs and invasiveness of blood sampling. Simple non-invasive tools to identify high risk individuals can facilitate screening. The main objectives of this study are to develop and validate a risk score for screening undiagnosed diabetes among Sri Lankan adults and to compare its performance with the Cambridge Risk Score (CRS), the Indian Diabetes Risk Score (IDRS) and three other Asian risk scores.MethodsData were available from a representative sample of 4276 adults without diagnosed diabetes. In a jack-knife approach two thirds of the sample was used for the development of the risk score and the remainder for the validation. Age, waist circumference, BMI, hypertension, balanitis or vulvitis, family history of diabetes, gestational diabetes, physical activity and osmotic symptoms were significantly associated with undiagnosed diabetes (age most to osmotic symptoms least). Individual scores were generated for these factors using the beta coefficient values obtained in multiple logistic regression. A cut-off value of sum = 31 was determined by ROC curve analysis.ResultsThe area under the ROC curve of the risk score for prevalent diabetes was 0.78 (CI 0.73–0.82). In the sample 36.3 % were above the cut-off of 31. A risk score above 31 gave a sensitivity, specificity, positive predictive value and negative predictive value of 77.9, 65.6, 9.4 and 98.3 % respectively. For Sri Lankans the AUC for the CRS and IDRS were 0.72 and 0.66 repectively.ConclusionsThis simple non-invasive screening tool can identify 80 % of undiagnosed diabetes by selecting 40 % of Sri Lankan adults for confirmatory blood investigations.

Summary Long-term use of exogenous glucocorticoids leads to the suppression of the hypothalamic–pituitary–adrenal axis. Therefore, if the glucocorticoid is withdrawn abruptly, patients will develop adrenal insufficiency. Hypercalcaemia is a rare but well-known complication of adrenal insufficiency. However, hypercalcaemia is a rare presentation of glucocorticoid-induced adrenal insufficiency (GI-AI). A 62-year-old patient with a past history of diabetes mellitus, ischaemic heart disease, stroke, hypertension and dyslipidaemia presented with polyuria, loss of appetite, malaise and vomiting for a duration of 2 months. His ionized calcium level was high at 1.47 mmol/L. Intact parathyroid hormone was suppressed (4.3 pg/mL) and vitamin D was in the insufficient range (24.6 ng/mL). Extensive evaluation for solid organ or haematological malignancy including contrast-enhanced CT chest, abdomen, pelvis, multiple myeloma workup and multiple tumour markers were negative. His synacthan-stimulated cortisol was undetectable thus confirming adrenal insufficiency. His adrenocorticotrophic hormone level was 3.82 pg/mL (4.7–48.8) excluding primary adrenal insufficiency. His MRI brain and other pituitary hormones were normal. Further inquiry revealed that the patient had taken over-the-counter dexamethasone on a regular basis for allergic rhinitis for more than 2 years and had stopped 2 weeks prior to the onset of symptoms. Therefore, a diagnosis of GI-AI leading to hypercalcemia was made. The patient was resuscitated with intravenous fluids and replacement doses of oral hydrocortisone were started with a plan of prolonged tailing off to allow the endogenous adrenal function to recover. His calcium normalized and he made a complete recovery. Learning points Long-term use of glucocorticoids leads to the suppression of the hypothalamic–pituitary–adrenal axis. If the glucocorticoid is withdrawn abruptly, patients will develop adrenal insufficiency which is known as glucocorticoid-induced adrenal insufficiency. Adrenal insufficiency should be considered in the differential diagnosis of parathyroid hormone-independent hypercalcaemia. A thorough clinical history is of paramount importance in arriving at the correct diagnosis.

A 48-year-old patient with a history of diabetes mellitus, presented to a surgical ward with abdominal pain. She was found to have hypokalemia. Her younger sister had passed away due to sudden cardiac death at the age of 25 years. Further evaluation revealed an elevated trans-tubular potassium gradient suggestive of renal potassium loss, normal blood pressure, hypomagnesemia, hypocalciuria, and alkalosis. Moreover, there was evidence of secondary hyperaldosteronism. Genetic studies revealed two heterozygous mutations of the SLC12A3 gene, including a novel mutation which has not been reported before anywhere in the world. She was treated with intravenous potassium supplementation and was later converted to oral potassium and oral magnesium supplementation with spironolactone. Her potassium and magnesium levels normalized and glycaemic control also improved. Hypokalemia and hypomagnesemia found in Gitelman syndrome may be associated with insulin resistance and correction of electrolytes can lead to better glycaemic control.

Background Prevalence of hyperglycaemia in pregnancy is on the rise. Both gestational diabetes mellitus and pre-existing diabetes mellitus are linked to several maternal and foetal/neonatal complications. We describe the diagnosis, management and maternal, neonatal outcomes of hyperglycaemia in pregnancy and compare these variables between mothers with gestational diabetes mellitus and mothers with pre- existing diabetes mellitus in a rural district of Sri Lanka recovering from the effects of decades of civil war. Methods A retrospective cross sectional descriptive study was conducted among mothers with gestational or pre-existing diabetes with a singleton pregnancy, who delivered in the obstetric ward of district general hospital of Vavuniya from 01/10/2018 to 31/10/2019. Consecutive sampling was used. Results Mean age of the participants (n = 324) was 30.07 ± 4.63 (± SD) years. Post prandial blood glucose was checked in 88.8% during the booking visit. Pre-existing diabetes mellitus was detected in 13.5% of mothers. Medical nutrition therapy alone was used in the management of 54.01% of mothers. Addition of metformin alone was needed in 36.7% and 9.2% required combination therapy with metformin and insulin. There were no maternal deaths, intra uterine deaths or still births. Operative delivery was required in 46.3% of mothers. Birth weight > 3.5kg was observed in 13.3% of newborns. Low birth weight (birth weight < 2.5 kg) was noted in 5.2%. There were no cases of shoulder dystocia. Sixteen (4.93%) babies had minor complications. Post-partum complications were noted only in 7 (2.16%) mothers. Post-partum blood sugar levels were performed in 86.7% mothers. Neonatal complications and low birth weight were significantly higher among mothers with pre-existing diabetes. Conclusions We observed low rates of maternal and neonatal complications among mothers with hyperglycaemia in pregnancy. Re-establishment of public health system in these rural areas in the post-war period probably contributed to this. Mothers with pre-existing diabetes had significantly higher rates of low birth weight and neonatal complications compared to mothers with gestational diabetes mellitus. A significant number of mothers missed post-partum blood sugar testing which is an area that could be improved.