Introduction: Pheochromocytoma is a catecholamine-secreting adrenal tumor associated with major perioperative hemodynamic instability. When concurrent major pelvic pathology requires surgery, operative planning becomes particularly challenging. We describe the successful single-stage management of pheochromocytoma and a giant uterine fibroid, highlighting the importance of multidisciplinary coordination and perioperative optimization. Case: A 49-year-old female with symptomatic uterine fibroid was found to have proliferative endometrium on a pipelle biopsy. Computed tomography (CT) abdomen incidentally detected a right adrenal mass alongside a large posterior uterine fibroid (11.9 × 17.4 × 14.6 cm). CT adrenal protocol demonstrated a heterogeneously enhancing right adrenal mass (6.9 × 6.9 × 9.6 cm) with high unenhanced attenuation. Biochemical evaluation revealed markedly elevated 24-hour urinary metanephrine (4.7× upper limit) and normetanephrine (2.4× upper limit). Following multidisciplinary discussions, a single-stage surgical approach was planned after careful assessment of feasibility and perioperative risk in view of the uncertain malignant potential of the pelvic mass and to minimize repeated exposure to anesthesia. Preoperative optimization included transitioning from terazosin to phenoxybenzamine, with subsequent addition of bisoprolol for hemodynamic control. The operative strategy prioritized pheochromocytoma resection first, given its potential for significant hemodynamic instability. Progression to hysterectomy was contingent upon achieving adequate intraoperative hemodynamic stability following adrenalectomy, with continuous reassessment by the anesthetic and surgical teams. Right adrenalectomy was performed first, followed by total abdominal hysterectomy with bilateral salpingooophorectomy. Significant hemodynamic lability occurred during tumor manipulation, with hypertensive surges managed using sodium nitroprusside and remifentanil infusions. Following adrenal vein ligation and tumor removal, hypotension was managed with noradrenaline and additional adrenaline support as required. Total operative time was approximately 6 hours. Postoperatively, transient noradrenaline support was required but was rapidly weaned as hemodynamic stability was achieved. Conclusion Single-stage adrenalectomy and major pelvic surgery can be safely performed in selected patients with pheochromocytoma when guided by meticulous preoperative optimization, clear intraoperative sequencing, and close multidisciplinary coordination.
Pheochromocytoma ; Adrenalectomy ; Leiomyoma ; Hysterectomy

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication associated with significant morbidity and healthcare burden. Despite advances in diabetes care, recurrent DKA remains common, often reflecting gaps in treatment adherence and patient education. Identifying predictors of recurrence is crucial for risk stratification and targeted intervention. Methodology: We conducted a retrospective observational study of all adult DKA admissions to a tertiary centre between 2001 and 2025. Electronic medical records were reviewed for demographic data, biochemical parameters, precipitating factors, and clinical outcomes. DKA was defined using standard biochemical criteria. Recurrent DKA was defined as ≥2 admissions during the study period. Factors associated with recurrent DKA admissions were analyzed. Patients under the age of 18 years and those with missing vital information were excluded. Results: A total of 667 DKA admissions, comprising 566 patients, were identified, of which 101 admissions (15.1%) were recurrent, involving 65 patients. Among recurrent DKA episodes, the most common precipitating factors were infection (64.4%) and insulin omission (62.4%). After multivariate analyses, patients with type 1 diabetes mellitus (T1DM) were more likely to develop recurrent DKA compared to those with type 2 diabetes mellitus (aOR 4.16; 95% confidence interval [CI] 2.58–6.70; p <0.001). Insulin omission was strongly associated with recurrent DKA (aOR 2.29; 95% CI 1.46–3.60; p <0.001). In contrast, baseline glycated hemoglobin and chronic kidney disease were not significantly associated with recurrence. Diabetic counseling during the first DKA admission did not reduce recurrent DKA. There were no significant differences in mortality (3.9% vs 6.2%, p = 0.524) or critical care admission rates (40.6% vs 38.7%, p = 0.718) between recurrent and first DKA episodes. Conclusion Recurrent DKA accounts for a substantial proportion of DKA admissions and is strongly associated with insulin omission and T1DM. Our findings suggest that recurrent DKA is driven predominantly by behavioral and adherencerelated factors, indicating the need for multidisciplinary interventions beyond standard inpatient counseling.
Diabetic Ketoacidosis ; Retrospective Studies

Introduction: Improving glycemic control while minimizing unnecessary insulin exposure is an important goal in diabetes management. The Rapid Optimization Clinic (ROC) was established as a structured multidisciplinary service to support therapy individualization, close follow-up, and timely insulin deintensification. This audit evaluated early changes in glycated hemoglobin A1c (HbA1c) and insulin treatment burden following ROC care over 3 months. Methodology: We conducted a retrospective audit of routine clinical data from patients with diabetes managed in the ROC at a district hospital. Baseline and 3-month HbA1c and insulin data were extracted from non-electronic clinic records. Insulin dose was standardized as total daily dose (TDD) in units/kg/day. Insulin deintensification was evaluated primarily by change in TDD from baseline to 3 months and by the proportion of patients who discontinued insulin during follow-up. Paired analyses were performed for patients with complete baseline and follow-up data for each outcome. Continuous variables are presented as mean ± standard deviation or median with interquartile range, as appropriate. Exploratory analyses were undertaken to assess whether available patient factors were associated with HbA1c improvement. Results: Twenty-three patients were included. Paired HbA1c data were available for 12 patients, whereas paired TDD data were available for 21 patients. Mean HbA1c decreased from 10.78 ± 2.59% at baseline to 8.42 ± 2.29% at 3 months, representing a mean reduction of 2.36 percentage points (95% confidence interval [CI] 0.09–4.62; p = 0.043). Mean TDD decreased from 0.434 ± 0.248 to 0.286 ± 0.313 units/kg/day, corresponding to a mean reduction of 0.148 units/kg/day (95% CI 0.077–0.219; p <0.001). Insulin was discontinued in 9 of 21 patients (42.9%). No clear association was observed between HbA1c improvement and age, sex, or number of visits. Interpretation is limited by the small sample size, reflecting the early phase of a newly established clinic. Conclusion In this early audit, ROC care was associated with clinically meaningful improvement in glycemic control and significant insulin deintensification over 3 months. These findings support the potential role of a structured multidisciplinary optimization clinic in delivering individualized diabetes care and facilitating safe reduction of insulin burden.
Humans ; Glycemic Control ; Retrospective Studies ; Diabetes Mellitus ; Insulins