Introduction: Managing thyroid storm requires aggressive multimodal therapy. However, options become exceptionally narrow when absolute contraindications to antithyroid drugs (ATDs) exist or standard therapy fails. In these refractory scenarios, therapeutic plasma exchange (TPE) serves as a critical rescue modality to optimize clinical and biochemical status. Despite its use, reported efficacy remains inconsistent. Cases: A 56-year-old female with Graves’ disease presented with thyroid storm (BWPS 60) complicated by high-output heart failure and distributive shock. Deterioration into acute liver failure (ALF) necessitated ATD discontinuation. TPE and Continuous Veno-Venous Hemofiltration (CVVH) were initiated at 40 hours. Following three TPE cycles, fT4 (freeT4) reduced by 6.7, 6.5, and 23% sequentially, leading to marked clinical stabilization and recovery. A 31-year-old female with Graves’ disease presented with thyroid storm (BWPS 90), pneumonia, and refractory tachycardia. Rising transaminases precluded ATD use. TPE was initiated at 48 hours, achieving a 55% fT4 reduction after 2 cycles and initial clinical stabilization. However, her course was complicated by a subdural hemorrhage requiring craniectomy; she eventually succumbed to nosocomial infection. A 27-year-old female with Graves’ disease presented with jaundice and altered sensorium (BWPS 45). Due to baseline ALF, ATDs were withheld. TPE was initiated early as a bridge to potential liver transplantation, achieving a significant 72% fT4 reduction after two cycles. Despite biochemical success, she succumbed to irreversible multi-organ failure. Conclusion Literature indicates that TPE achieves a mean fT4 reduction of 51.9% over four cycles. Our series demonstrated wide variability (23–72% over 2–3 cycles), reflecting unpredictable clearance dynamics. While TPE is an effective adjunctive tool for rapid biochemical optimization, the ultimate prognosis is heavily contingent on the timing of initiation. As seen in Cases 2 and 3, significant biochemical clearance may not reverse systemic damage once advanced neurological or hepatic failure ensues

Introduction: The 2021 IDF-DAR risk calculator had been previously evaluated in multiple studies and subsequently widely accepted and applied in clinical practice as a practical standardized tool for patient risk stratification. Recently updated, the 2026 IDF-DAR Risk calculator enables a more individualized, evidence-related evaluation of patientrelated and disease-related risk factors, incorporating modern diabetes technologies, including continuous glucose monitoring (CGM), automated insulin delivery (AID) systems, and advanced insulin formulations to enhance risk stratification. This tool allows medical professionals to tailor Ramadan practices based on overall factors toward promoting safe fasting. Methodology: This prospective multicentre observational study recruited adults with Type 1 and Type 2 diabetes attending public hospitals nationwide. People with diabetes (PwD) intending to perform Ramadan fasting were invited to participate and assessed using the 2026 IDF-DAR Risk Calculator in the 6-week pre-Ramadan period between 30th January and 19th March 2026. Results: A total of 458 PwD were evaluated and stratified into low (15.7%), moderate (41%), and high risk (43.3%) categories. Most participants had Type 2 diabetes (83.6%), with 60.3% having a disease duration exceeding 10 years and 43% exhibiting poor glycemic control (hemoglobin A1c >9%). Insulin therapy was used by 76.4% of participants, including two individuals with Type 1 diabetes using AID systems. Most participants reported no recent hypoglycemia (76.4%), 81.0% performed glucose monitoring, and 3.3% used CGM. Severe comorbidities were uncommon, with 1.1% having unstable macrovascular disease and 4.4% advanced chronic kidney disease (estimated glomerular filtration rate <30). Notably, 72.2% received structured Ramadan education. Conclusion Majority of PwD attending tertiary diabetes clinics were in the moderate- to high-risk category and intended to fast despite medical advice against fasting in some cases. Although most participants were on insulin therapy, hypoglycemia was low in the pre-Ramadan period. Integration of modern technologies, advanced insulin therapies, and structured education may support safer fasting practices.
Risk Assessment ; Diabetes Mellitus ; Hospitals ; Fasting

A collision tumor involving metastasis to a pituitary adenoma is rare. We describe a case of a 68-year-old Bidayuh woman with underlying treatment-responsive lung adenocarcinoma, who presented with mass effect, panhypopituitarism and polyuria. Her initial imaging study reported pituitary macroadenoma, and she was treated with hormone replacement therapy. She then underwent transsphenoidal tumor debulking surgery with subsequent histopathological findings of a collision tumor of an adenocarcinoma with metastasis to a non-functioning pituitary adenoma.
Pituitary Neoplasms