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Fulltext Reappraisal of bovril as a source of arginine in the arginine stimulation test for growth hormone deficiency

Loh HH, Norlela S, Nor Azmi K

Med J Malaysia, 2015 Jun;70(3):208-9.
PMID: 26248787 MyJurnal

The purpose of this case study is to report the use of oral Bovril (a food supplement which contains arginine) as an alternative test for growth hormone stimulation test. We performed oral Bovril test in 3 patients -- one with suspected growth hormone deficiency in whom insulin tolerance test could not be performed (subject A), one sex-matched control (subject B), and one with confirmed growth hormone deficiency (subject C). 14g/m(2) of oral Bovril was mixed with 150ml of warm water and was given to all three subjects. Blood for growth hormone was taken at baseline, and every 30 minutes till 150 minutes after ingestion of oral Bovril. The ingestion of oral Bovril showed a positive response in subjects A and B, with highest growth hormone levels of 28.4mIU/L and 42.0mIU/L respectively at 150 minutes. Subject C had suppressed growth hormone throughout the test. Oral Bovril is readily available and is a safe alternative for standard growth hormone stimulation test.
Fulltext Renal cell carcinoma in a von Hippel-Lindau syndrome: when should phaeochromocytoma be anticipated?

Azarisman SM, Nor Azmi K

Singapore Med J, 2007 Aug;48(8):779-82.
PMID: 17657389

A 39-year-old man was diagnosed with von Hippel-Lindau syndrome, which was associated with retinal haemangioblastoma, cervical cord haemangioblastoma and bilateral renal cell carcinoma. He subsequently underwent an arterial embolisation and cervical laminectomy, following a spinal angiogram of the cervical lesion. He also had a right radical nephrectomy, with no perioperative complications. However, on admission for the left radical nephrectomy, he was noted to have preoperative hypertension. Further investigation revealed an enlarged left adrenal gland on abdominal computed tomography scan and raised urinary catecholamines. We discuss the risk of renal cell carcinoma and phaeochromocytoma arising concomitantly in von Hippel-Lindau syndrome, and how best to investigate and manage them.
Fulltext A ten-year retrospective analysis of gastroenteropancreatic neuroendocrine tumors (GEP-NETs) in Malaysia

Gunavathy M, Rohana AG, Norlela S, Nor Azmi K

Med J Malaysia, 2014 Jun;69(3):133-7.
PMID: 25326355 MyJurnal

Gastroenteropancreatic neuroendocrine tumours (GEP- nETs) are rare neoplasms with a complex spectrum of presentation. The study cohort (n=64) included the diagnoses of carcinoid, (n=26, 41%), insulinoma, (n=25, 39%), undetermined (n=10, 16%), VIPoma, glucagonoma and multiple endocrine neoplasia (MEn-1) (n= 3). Almost half of the patients (n=31) had distant metastasis at diagnosis, the commonest being carcinoid tumours. Presenting symptoms were due to either hormonal expressions or mass effects. diagnoses in all patients were made based on positive immunohistochemical staining for chromogranin and synaptophysin. Less than half (n=30) had either serum chromogranin A, urinary 5-hydroxyindole acetic acid (5-hIAA), serum insulin or C-peptide levels performed. Commonest diagnostic imaging modalities were computed tomography (CT) scan (94%) and abdominal ultrasound (15%). Curative or palliative surgery was performed in 58 patients. Systemic therapy included long acting somatostatin analogues (n=14), chemotherapy (n=7) and interferon-α2b (n=1). nine patients died, all of who had metastatic disease at diagnosis. All patients with insulinoma (n=25) were assessed by endocrinologists whilst carcinoid tumours were mainly managed by surgeons (n=16/26). Involvements of oncologists and gastroenterologists were minimal. This study showed that patients with GEP-nETs in Malaysia commonly presented late in the disease with presence of distant metastases. Less than half had adequate hormonal and biochemical examinations performed for diagnostic as well as prognostic purposes, and only a third received systemic therapy. Lack of institutionalbased database, clinical expertise and multi-disciplinary involvement contributed to the inadequate surveillance and management of the disease.
Spot urine potassium as a potential screening test for aldosterone breakthrough

Sakthiswary R, Wong M, Isa ZM, Nor Azmi K

Clin Ter, 2012;163(3):195-8.
PMID: 22964690

Treatment with angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) may suppress aldosterone production only in the initial phase of treatment and subsequently lead to a rising level of aldosterone to baseline or higher. This phenomenon is described as aldosterone breakthrough. Apart from serial plasma aldosterone levels, there are no other test to identify this condition. The purpose of this study was to evaluate the role of spot urine potassium as a potential screening test for aldosterone breakthrough.
Fulltext Pituitary thyroid resistance syndrome

Norlela S, Nor Azmi K, Khalid BAK

Med J Malaysia, 2005 Dec;60(5):642-3.
PMID: 16515117

Thyroid hormone resistance (RTH) is a rare autosomal dominant disorder, characterized clinically by goiter and biochemically by elevated circulating free thyroid hormone levels in the presence of measurable serum thyroid-stimulating hormone (TSH) concentrations. About 85% of patients with RTH harbor mutations in thyroid hormone receptor [beta] (TR[beta]). Even rarer is pituitary thyroid resistance syndrome. We report a case of a 35-year-old man who presented with hypermetabolic symptoms with elevated levels of thyroid hormones, associated with nonsuppressed thyrotropin (TSH). When treated with anti-thyroid drugs, his thyroid hormone levels normalized and TSH increased, suggesting thyroid resistance at the pituitary level.
MMP-9: biomarker for abdominal aneurysm

Affirul CA, Azim IM, Hanafiah H, Nor Azmi K, Rozman Z

Clin Ter, 2013;164(6):e479-83.
PMID: 24424226 DOI: 10.7417/CT.2013.1640

INTRODUCTION: Matrix Metalloproteinase 9 (MMP-9) has been shown to express significantly on organ tissue culture in Abdominal Aortic Aneurysm (AAA) patients. Prior studies have shown the correlation between MMP-9 concentration levels with AAA raising the probability of its usage as a biomarker in AAA disease. However, results of previous studies have been conflicting. The purpose of this study is to identify the correlation between MMP-9 concentration levels with AAA disease and further define the utility as a biomarker for our center population.
MATERIALS AND METHODS: This is prospective controlled trial. Peripheral venous blood sample is obtained from 20 patients with AAA and 36 normal control subjects. MMP-9 concentration levels were determined by an enzyme-linked immunosorbent assay and compared with subjects abdominal ultrasonography or computed tomography of abdomen.
RESULTS: Mean (± SE) MMP-9 was 23.94 ± 0.60 ng/mL in normal control subjects and 21.39 ± 1.03 ng/mL in patients with AAAs (p ← 0.05 versus normal control subjects). MMP-9 correlate significantly with AAA (p=0.004). There was no correlation of MMP-9 levels with age, gender, or other risk factors. The cutoff point is 12.54 for aorta size <3.0 cm. The sensitivity and specificity of MMP-9 were 60% and 64% respectively.
CONCLUSIONS: MMP-9 levels correlate significantly with AAA with a cutoff point of 12.54. However, the utility of MMP-9 as a diagnostic test is limited due to low sensitivity and specificity. An elevated MMP-9 has limited use to predict the presence of AAA (positive predictive value: 60%) and a normal MMP-9 level was insufficient to determine the absence of AAA (negative predictive value: 36.1%).
Fulltext Adrenal insufficiency in acute coronary syndrome

Norasyikin AW, Norlela S, Rozita M, Masliza M, Shamsul AS, Nor Azmi K

Singapore Med J, 2009 Oct;50(10):962-6.
PMID: 19907885

Acute coronary syndrome (ACS) is an acute stressful condition which stimulates the hypothalamus-pituitary-adrenal axis that regulates neurovascular and hormonal responses. Functional hypoadrenalism has been shown to be associated with significant morbidity and mortality in the critically-ill patient, but there is to date no known study done to determine its prevalence in patients with ACS.
Improvement of dietary quality with the aid of a low glycemic index diet in Asian patients with type 2 diabetes mellitus

Barakatun Nisak MY, Ruzita AT, Norimah AK, Gilbertson H, Nor Azmi K

J Am Coll Nutr, 2010 Jun;29(3):161-70.
PMID: 20833988 DOI: 10.1080/07315724.2010.10719830

OBJECTIVES: This randomized controlled study was conducted to determine the effect of low glycemic index (GI) dietary advice on eating patterns and dietary quality in Asian patients with type 2 diabetes (T2DM).

METHODS: Asian patients with T2DM (N = 104) were randomized into 2 groups that received either low GI or conventional carbohydrate exchange (CCE) dietary advice for 12 weeks. Nutritional prescriptions were based on the medical nutrition therapy for T2DM, with the difference being in the GI component of the carbohydrates. Dietary intake and food choices were assessed with the use of a 3-day food record.

RESULTS: At week 12, both groups achieved the recommendations for carbohydrate (52 ± 4% and 54 ± 4% of energy) and fat (30 ± 4% and 28 ± 5% of energy) intake. There were no significant differences in the reported macronutrient intake in both groups. With the low GI diet, crude fiber and dietary calcium intake increased, while the dietary GI reduced. Subjects in the lowest dietary glycemic index/glycemic load (GI/GL) quartile consumed more parboiled/basmati rice, pasta, milk/dairy products, fruits, and dough, which are foods from the low GI category. There was a significant reduction in the hemoglobin A(1c) level at week 12 for patients in the lowest GI/GL quartile (Δ = -0.7 ± 0.1%) compared with those in the highest GI/GL quartile (Δ = -0.1 ± 0.2%).

CONCLUSIONS: These results demonstrate the ability of low GI dietary advice to improve the dietary quality of Asian patients with T2DM.
Role of probiotics in modulating glucose homeostasis: evidence from animal and human studies

Firouzi S, Barakatun-Nisak MY, Ismail A, Majid HA, Nor Azmi K

Int J Food Sci Nutr, 2013 Sep;64(6):780-6.
PMID: 23484591 DOI: 10.3109/09637486.2013.775227

Evidences from several studies suggest that probiotics affect glucose homeostasis. This paper reviews the results of animal and human studies on the role of probiotics in modulating glucose homeostasis.
Fulltext Lowering dietary glycaemic index through nutrition education among Malaysian women with a history of gestational diabetes mellitus

Sangeetha-Shyam, Fatimah A, Rohana AG, Norasyikin AW, Karuthan C, Nik SS, et al.

Malays J Nutr, 2013 Apr;19(1):9-23.
PMID: 24800381 MyJurnal

Introduction: Gestational diabetes mellitus (GDM) increases risks for type 2
diabetes and cardiovascular diseases. Low glycaemic index (GI) diets improve
cardio-metabolic outcomes in insulin-resistant individuals. We examined the
feasibility of lowering GI through GI-based-education among Asian post-GDM
women. Methods: A 3-month investigation was carried out on 60 Malaysian
women with a mean age of 31.0±4.5 years and a history of GDM. Subjects were
randomised into two groups: LGIE and CHDR. The CHDR group received
conventional healthy dietary recommendations only. The LGIE group received
GI based-education in addition to conventional healthy dietary recommendations.
At baseline and after 3-months, dietary intake of energy and macronutrient
intakes including GI diet and glycaemic load was assessed using 3-day food
records. Diabetes-Diet and GI-concept scores and physical activity levels were
assessed using a questionnaire. Adherence to dietary instructions was measured
at the end of 3 months. Results: At the end of 3 months, the LGIE group had
significant reductions in energy intake (241.7±522.4Kcal, P=0.037, ES=0.463), total
carbohydrate (48.7±83.5g, P=0.010, ES=0.583), GI (3.9±7.1, P=0.017, ES=0.549) and
GL (39.0±55.3, P=0.003, ES=0.705) and significant increases in protein (3.7±5.4g,
0.003, ES=0.685) and diet fibre (4.6±7.3g, P=0.06). The CHDR group had a significant
reduction in fat only (5.7±9.4g, P=0.006, ES=0.606). There was a 30% increase in
GI-concept scores in the LGIE group (p< 0.001). Changes in GI-concept scores
correlated significantly to the reduction in dietary GI (r = -0.642, P=0.045). Dietary
adherence was comparable in both groups. Conclusion: GI-education improves
GI-concept knowledge and helps lower dietary glycaemic index among women
with a history of GDM.
Keywords: Diet, gestational diabetes mellitus, glycaemic index, glycaemic load,
prevention, type 2 diabetes
Fulltext Pheochromocytoma and pregnancy: a difficult and dangerous ordeal

Mohamed Ismail NA, Abd Rahman R, Abd Wahab N, Muhammad R, Nor Azmi K

Malays J Med Sci, 2012 Jan;19(1):65-8.
PMID: 22977377 MyJurnal

Pheochromocytoma during pregnancy is potentially disastrous to the mother and fetus. Its ambiguous presentation is often mistaken for pre-eclampsia, although it may imitate other problems during pregnancy. Early diagnosis and timely, appropriate management reduces possible maternal and fetal complications. We identified a case of pheochromocytoma during pregnancy; the condition was initially diagnosed as pre-eclampsia complicated with gestational diabetes. Surgical intervention via left adrenalectomy was successfully performed in the second trimester. After surgery, all of the patient's medical problems nearly subsided and she did not require further treatment. However, her fetus displayed restricted intrauterine growth, and the patient eventually had premature delivery via a caesarean section. A multidisciplinary team to identify and treat pheochromocytoma is mandatory to ensure optimal conditions for tumour removal and to anticipate any possible catastrophic events.
Serum Vitamin D levels in patients with chronic kidney disease

Rozita M, Noorul Afidza M, Ruslinda M, Cader R, Halim AG, Kong CT, et al.

EXCLI J, 2013;12:511-20.
PMID: 26933400

Hypovitaminosis D is reported to be associated with several medical complications. Recent studies have reported a high worldwide prevalence of Vitamin D deficiency in the general population (up to 80 %). This is even higher in patients with chronic kidney disease (CKD) and increases with advancing stages of CKD.