bluuebunny/crossref_metadata_2025 huggingface dataset:
THU261 Etiologic Factors, Contributors, And Associations For Exocrine Pancreatic Insufficiency
Authors: Romo Karina G , Noor Abdulla , Zia Abdul , Shu Sharon , Bhamre Sneha , West William A , Hoard Brandon M , Uwaifo Gabriel I
Published: October 2023

Disclosure: K.G. Romo: None. A. Noor: None. A. Zia: None. S. Shu: None. S. Bhamre: None. W.A. West: None. B.M. Hoard: None. G.I. Uwaifo: None.

Introduction: Exocrine pancreatic insufficiency (EPI) is a clinical condition which though presumed to be uncommon has grown in prominence and recognition in recent years. The fact that pancreatic enzyme replacement therapy (PERT) is available to ameliorate many of the metabolic and gastrointestinal sequelae of EPI makes its early recognition, diagnosis, and treatment very important. Since EPI appears uncommon, improved quantification of its prevalence and identification of associated etiologic factors could inform targeted screening in select patient populations. Our study is a retrospective chart analysis of a large multi-specialty, multi-institutional practice group covering much of Louisiana and seeks to provide needed information regarding EPI prevalence and etiologic factors. Methods: A retrospective review of the entire 1.3 million patient-practice of the Ochsner Health system in Louisiana was performed to cover the period from January 2017 to January 2020. All cases of documented EPI and patients on PERT were identified—these were then further interrogated including individual chart review to identify etiologic factors and obtain relevant cardiometabolic, demographic, vital sign data, and clinical course information. Results: A total of 677 EPI patients were identified with a prevalence of 0.525% among patients with diabetes (DM) and 0.051% in the general outpatient population. EPI, though uncommon, is thus ∼ 10x more prevalent among DM patients. The identified etiologic factors were Type 2 diabetes (T2DM) (44.6% of cases), general cancer (15.9%), secondary diabetes (11.5%), cystic fibrosis (12.9%), Type 1 diabetes (T1DM) (9.6%), pancreatic cancer (6.6%), idiopathic (6.2%), pancreatitis (5%), pancreatic surgery (2.95%), hemochromatosis-hemosiderosis (0.44%), and alpha-1 antitrypsin deficiency (0.15%). Several patients in the cohort had multiple identified etiologic factors. Discussion and Conclusions: While EPI is uncommon in the general population it is at least 10x more prevalent among DM patients. Etiologic factors provide a clinical pathway for targeted clinical and lab screening to enable early diagnosis and treatment. Since T2DM is the most common etiologic factor for EPI in our cohort and other reported series, there is need for further in-depth study to identify potentially modifiable factors and possible predictors in the progression of DM to EPI and whether PERT can ameliorate associated cardio-metabolic and ASCVD risk surrogates.

Presentation: Thursday, June 15, 2023
THU271 Identification Of Candidate Biomarkers For Type 1 Diabetes Mellitus By Bioinformatics Analysis Of Pooled Microarray Gene Expression Datasets In Gene Expression Omnibus
Authors: Feng Kevin , Chen Wenqiang
Published: October 2023

Disclosure: K. Feng: None. W. Chen: None.

Background: Type 1 diabetes (T1DM) is a serious threat to childhood life and has a complicated pathogenesis. Currently, molecular mechanisms of T1DM remain largely unclear. The aim of this study was to identify the candidate genes in T1DM by integrated bioinformatics analysis. Methods: Transcriptomic datasets (GSE156035) in the GEO database were analyzed for differentially expressed genes (DEGs) using the R statistical language. The differentially expressed genes (DEGs) were identified, and the Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed. A protein - protein interaction (PPI) network was applied to screen out the candidate genes. Results: The results revealed that 273 DEGs of the three datasets were ascertained in our study, including 135 upregulated genes and 138 downregulated genes. The GO and KEGG enrichment analysis results showed that the functions of DEGs mainly involved in regulation of transcription from RNA polymerase II promoter, specific granule lumen, transcriptional activator activity, Osteoclast differentiation pathway, etc. Through the PPI analysis network, the core genes with the highest degree of 6 nodes were selected: FOS, RHOA, CXCL8, FOSB, EGR1, and DUSP1. Conclusion: The genes, identified in this study, may play a vital regulatory role in the occurrence and development of T1DM. Also, they are closely related to obesity and diabetes mellitus. Our results provide novel biomarkers that could be used as representa­tive reference indicators or potential therapeutic targets for T1DM clinical applications.

Presentation: Thursday, June 15, 2023
THU288 An Analysis Of The Association Between Age, HbA1c, Central Corneal Thickness, And Lens Thickness Using Swept-source Optical Coherence Tomography
Authors: Borkhetaria Rucha K , Karakoleva Ema V , Devireddy Nitya , Rosen David B , Pantanelli Seth M
Published: October 2023

Disclosure: R.K. Borkhetaria: None. E.V. Karakoleva: None. N. Devireddy: None. D.B. Rosen: None. S.M. Pantanelli: None.

An increase in age is positively correlated with an increase in the thickness of the crystalline lens of the eye. Lens thickness changes have also been observed in diabetics. However, whether a predictable relationship exists between HbA1c and certain biometric variables is unknown. The aim of this study was to investigate any associations between age, HbA1c levels, central corneal thickness (CCT), and lens thickness (LT) using a swept-source optical coherence tomography (SS-OCT) based optical biometer in the eyes of patients with diabetes mellitus. A retrospective, consecutive case series was conducted. CCT and LT were measured with the IOLMaster 700 swept-source optical biometer (Carl Zeiss Meditec). HbA1c of diabetics recorded within 3 months of biometry measurements were abstracted from the medical record. The data were analyzed using a linear regression model. We evaluated 391 eyes of 391 patients: 107 diabetics and 284 age-matched non-diabetics. Amongst non-diabetics, age was positively associated with LT (p<0.001), with an increase in LT of 0.02 mm per year of age. There was no association elucidated between age and CCT in this group (p=0.754). Amongst diabetics, HbA1c was independently associated with LT (p=0.005) after controlling for age, with a decrease in LT of 0.07 mm per 1-unit increase in HbA1c. Age (p=0.119) nor HbA1c (p=0.310) were associated with CCT amongst diabetics. There was a positive correlation between age and lens thickness amongst diabetics and non-diabetics. HbA1c was independently associated with lens thickness amongst diabetics. There was no correlation between age, HbA1c, and central corneal thickness.

Presentation: Thursday, June 15, 2023
THU290 Identifying Trends In Glycemic Management In A Comprehensive Cancer Center
Authors: Kikani Nupur , Thosani Sonali
Published: October 2023

Disclosure: N. Kikani: None. S. Thosani: None.

Hyperglycemia in the inpatient setting contributes to morbidity and mortality. Glycemic management in the emergency room is the gateway for inpatient management. An institutional quality improvement initiative to improve glycemic management was initiated in January 2020. Interventions included a diabetes related questionnaire at triage triggering a mandatory point of care (POC) glucose check if positive and the addition of quick access acute hyperglycemia orders in the emergency management electronic medical record (EMR) order set. In this study, we gathered baseline glycemic data on patient visits to urgent care center from January 2019-November 2022 to explore trends in monitoring and management prior to and after the implementation of initiative.

The highest value of glucose documented per encounter was utilized for calculations. During this period, an average of 1,912 individual patients were evaluated and accounted for 2,239 visits per month. For the entire patient population, 7% of visits were characterized by glucose values between 200-249mg/dL, 3% of visits with glucose values between 250-299 mg/dL, and 2% with glucose values ≥300mg/dL. 59% of visits resulted in inpatient admission and 25% of admitted patients had point of care glucose monitoring orders.

17.8% of patients had known diabetes and on average, 24%, 13% and 8% of these patient visits were characterized by glucose between 200-249 mg/dL, 250-299 mg/dL and ≥300mg/dL respectively. 64% of visits culminated with inpatient admission with 46% of admitted patients having POC glucose monitoring orders and 79% of patients with insulin orders on admission.

In 2019, a mean of 25% of total admitted patient encounters had a POC glucose order on admission compared to 21% in 2020, 25% in 2021, and 30% in 2022. Of those patient encounters with known diabetes, 49%, 39%, 43%, 52% had a POC glucose order on admission in the years 2019, 2020, 2021, and 2022 respectively. Of the encounters with patients with known diabetes, 37% were admitted with an insulin sliding scale order in 2019, 26% in 2020, 26% in 2021, and 36% in 2022. In 2019, 76% of encounters with diabetes patients had an insulin order on admission, 80% in 2020, 79% in 2021, and 79% in 2022.

Over the four years, the mean distribution of POC blood glucose values remained stable across both the general and diabetes specific populations. The admission rate for both these populations also had little variability. Of the patients with diabetes, the rate of POC glucose order at admission increased from 49% to 52%. Those with an insulin order remained stable from 76% to 79%. Additionally, only 26% to 37% of patients with diabetes were admitted with an insulin sliding scale order. These trends provide valuable insight into areas that may be targeted for early intervention in glycemic management which has the potential to improve hospital outcomes in patients with diabetes mellitus.

Presentation: Thursday, June 15, 2023
THU302 Protective Effects Of Lactation On Maternal Metabolism
Authors: Hens Julie R , Ding Yuyan , Brown Stacey , Song Huijia , Wysolmerski John J , De Aguiar Renata Belfort
Published: October 2023

Disclosure: J.R. Hens: None. Y. Ding: None. S. Brown: None. H. Song: None. J.J. Wysolmerski: None. R. Belfort De Aguiar: None.

A history of lactation significantly lowers the risk of developing Type 2 diabetes (T2D) by almost 50%. However, little is known about how milk production durably changes maternal metabolism. We hypothesized that lactation protects against diabetes by improving maternal glucose metabolism. Changes in body composition, glucose metabolism, insulin secretion and tissue triglyceride levels were measured in age-matched cohorts of mice that lactated (L) or did not lactate but went through a pregnancy (NL); age-matched virgins served as controls (V). L and NL mice were studied 4 weeks after weaning of pups from the L group. An euglycemic-hyperinsulinemic clamp was used to further examine glucose metabolism. Multiple rounds of lactation were examined to determine if body composition or glucose metabolism changed with repeated cycles of reproduction. Liver weight was higher in L mice when compared to V mice. Liver triglycerides were lower in L and NL mice when compared to V mice. Circulating fasting levels of plasma free fatty acids were unchanged between the three groups. Perigonadal fat trended higher in NL mice compared to L and V mice after one round of lactation. However, after two rounds of lactation, NL mice had significantly more perigonadal fat than L or V mice. Fasting glucose trended lower in L mice compared to NL mice, but there was no difference in insulin levels between groups. The area under the curve of glucose tolerance test was not different between groups. Pancreases from L mice had increased numbers of islets compared to NL and V mice. Insulin action was assessed in chow-fed, conscious, unrestrained L, NL, and V mice using the euglycemic-hyperinsulinemic clamp technique. Tail-vein glucose was clamped at 100-120 mg/dL. The normalized glucose infusion rate to insulin was significantly lower (p=0.01) in NL mice (41.9 +/- 17) compared to V mice (91.8 +/- 14 and L mice (83.8 +/- 27). Our results suggest that pregnancy and lactation significantly alter the metabolic functions of liver, adipose, muscle, and pancreas. Furthermore, a history of lactation improves insulin sensitivity in parous mice. Further study of the metabolic changes occurring during lactation may have wide-ranging implications for women’s health.

Presentation: Thursday, June 15, 2023
THU308 Metabolic And Neuroendocrine Adaptability Following One Night Of Partial Sleep Restriction In Dutch Males
Authors: Pelsma Iris , den Berg Rosa van , Kooijman Sander , Snel Marieke , Zhu Gewei , Moore Alison , Pople Jenny , Lavrijsen Sjan , Birch-Machin Mark , Bhogal Ranjit , El Ghalbzouri Abdoelwaheb , Martinez-Tellez Borja , Giesbrecht Timo , Kersten Sander , Weeghel Michiel van , Cornelis Meijer Onno , Pereira Arias Alberto Martin , Gunn David , Rensen Patrick , Biermasz Nienke
Published: October 2023

Disclosure: I. Pelsma: None. R. van den Berg: None. S. Kooijman: None. M. Snel: None. G. Zhu: None. A. Moore: Employee; Self; Unilever. J. Pople: Employee; Self; Unilever. S. Lavrijsen: None. M. Birch-Machin: None. R. Bhogal: Employee; Self; Unilever. A. El Ghalbzouri: None. B. Martinez-Tellez: None. T. Giesbrecht: Employee; Self; Unilever. S. Kersten: None. M. van Weeghel: None. O.C. Meijer: None. A.M. Pereira Arias: None. D. Gunn: Employee; Self; Unilever. P. Rensen: None. N. Biermasz: None.

Introduction: Chronic and acute short sleep associate with many adverse effects. Metabolic and neuroendocrine effects during the day following short sleep, however, are unknown. Methods: Randomized cross-over study using short sleep (4h) vs normal sleep (8h) in 31 males (31 years (IQR 23-47, BMI 26.0±4.2 kg/m2 (range 20.1-35.0). Glucose, lipid, incretin, ACTH, and cortisol levels, as well as respiratory exchange ratio (RER; indirect calorimetry) were assessed following standardized mixed meals. RNAseq of morning skeletal muscle biopsies and pathway analysis on differentially expressed genes was performed. Results: Short sleep increased fasting free fatty acids (0.34 mmol/L (IQR 0.26 - 0.38) vs 0.47 mmol/L (IQR 0.38 - 0.70), P<0.0001). Cortisol levels peaked upon early wake-up, which eliminated a peak at normal wake-up. Morning postprandial glucose peaked later (time P<0.001, levels P=0.106, pattern P=0.031), whilst insulin was unaffected. Afternoon postprandial insulin was lowered (time P<0.001, levels P=0.044, pattern P=0.419), whilst glucose was unaffected. Morning and afternoon postprandial TC, and LDL-c were lowered (morning: TC, time P<0.0001, levels P=0.009, pattern P=0.289; LDL-c, time P<0.001, levels P=0.038, pattern P=0.797; afternoon: TC, time P<0.001, levels P=0.007, pattern P=0.92; LDL-c, time P<0.001, levels P=0.055, pattern P=0.991). Pathway analysis of muscle revealed increased fatty acid oxidation (FAO), reflected by increased Oxidative Phosphorylation and Mitochondrial Dysfunction pathways, accompanied by lowered fasting RER (0.87 (IQR 0.86 - 0.92) vs 0.86 (IQR 0.84 - 0.87), P=0.0033). Conclusions: Acute partial sleep restriction subtly and temporarily changed glucose dynamics (morning), and insulin levels (afternoon), and lowered TC and LDL-c levels in the morning and afternoon, with concurrent increased FAO and mitochondrial dysfunction pathways in skeletal muscle, and calorimetric shifting from glucose towards lipid oxidation (fasted and postprandial), potentially highlighting increased delipidation of chylomicrons following sleep restriction.

Presentation: Thursday, June 15, 2023
THU321 Indirect Effects Of COVID-19 On The Risk Of Gestational Diabetes And Factors Mediating Increased Risk
Authors: Rhou Yoon Ji J , Elhindi James , Melov Sarah J , Cheung N Wah , Pasupathy Dharmintra
Published: October 2023

Disclosure: Y.J. Rhou: None. J. Elhindi: None. S.J. Melov: None. N. Cheung: None. D. Pasupathy: None.

Aim: COVID-19 has had indirect effects on pregnancy outcomes. This study aimed to assess the risk of gestational diabetes (GDM) in distinct COVID-19 exposure periods and determine the potential factors contributing to increased risk of GDM in a multiethnic population. Methods: Multicentre, retrospective cohort study of singleton pregnancies at three hospitals two years pre-COVID-19 (January 2018 - January 2020), 1st year of COVID-19 with low COVID-19 pandemic burden and limited restrictions (February 2020 - January 2021), and 2nd year of COVID-19 with increased pandemic burden and stringent restrictions (February 2021 - January 2022). Baseline maternal characteristics, gestational weight gain (GWG) and pregnancy outcome data were compared between time periods. The primary outcome of GDM was assessed using univariate and multivariate generalized estimating equations models. Results: Of 28,207 pregnancies, 14,663 occurred in the two years pre-COVID-19, 6,890 in COVID-19 Year 1 and 6,654 in COVID-19 Year 2. The study population was diverse, comprising 82.5% of non-Caucasian ethnicity and 22.7% in the quintile of greatest socioeconomic disadvantage. Maternal age increased across exposure periods (30.7 ± 5.0 years pre-COVID-19 vs 31.0 ± 5.0 years COVID-19 Year 1 vs 31.3 ± 5 years COVID-19 Year 2; p<0.001). There were increases in prepregnancy BMI (25.5 ± 5.7 kg/m2 vs 25.7 ± 5.6 kg/m2 vs 26.1 ± 5.7 kg/m2; p<0.001), proportion who were obese (17.5% vs 18.1% vs 20.7%; p<0.001) and proportion with other traditional risk factors for GDM including South Asian ethnicity and prior history of GDM. Weekly rate of GWG and proportion exceeding recommended GWG increased across pandemic exposure periods (64.3% vs 66.0% vs 66.6%; p=0.009). GDM diagnosis increased across exposure periods (21.2% vs 22.9% vs 24.8%; p<0.001). Both COVID-19 Year 1 and Year 2 were associated with increased risk of GDM on univariate analysis, only COVID-19 Year 2 remaining significantly associated after adjusting for maternal baseline characteristics and GWG (OR 1.17 [1.06, 1.28], p=0.01). Conclusion: Diagnosis of GDM increased with pandemic exposure. Progressive sociodemographic changes and greater GWG may have contributed to increased risk. However, exposure to the 2nd year of COVID-19 remained independently associated with GDM after adjusting for shifts in baseline maternal characteristics and GWG.

Presentation: Thursday, June 15, 2023
THU323 Extreme Insulin Resistance In Type 1 Diabetic After Covid 19 Infection
Authors: Zakkar Adam A , Fadanelli Margaret , Al Mushref Mazen
Published: October 2023

Disclosure: A.A. Zakkar: None. M. Fadanelli: None. M. Al Mushref: None.

Patient is a 46-year-old African American female with a medical history of Diabetes Mellitus Type 1 for 20 years, hypothyroidism, rheumatoid arthritis and celiac disease who presented with a complaint of dizziness and heavy menstrual periods. When she presented, labs were significant for a glucose of 513 mg/dL, anion gap of 22 with a bicarbonate of 8, HbA1c of 10%, Hemoglobin of 8.1 and UA revealed ketones and she was thus started on an insulin drip for diabetic ketoacidosis. Patient was also complaining of a cough and weakness and thus a sputum sample was obtained which was positive for Streptococcus pneumoniae and she was started on antibiotics. At the time of arrival the patient was A&Ox4 and stated that her glucose has been really difficult to control over the last 6 months after she had been infected with COVID-19 and over that time she has also lost approximately 50 lbs. She stated that one month prior to the patient having COVID-19 infection, she was taking aspart 20 units per/meal and detemir 32 units qAM and 62 units qHS, and had an HbA1c of 8.5%. Just prior to presentation, the patient was taking 70 units of the U-100 aspart insulin per meal and 60 units of glargine U300 twice daily with persistent hyperglycemia. Insulin antibodies were tested and returned remarkably high. GAD-65 antibody was also high. The patient's glucose remained in the 500-600 mg/dL range and the acidosis worsened to a pH of 6.9 despite receiving continuous intravenous insulin aspart at 30units/hr with the addition of detemir 100 units q12-hours. The patient's acidosis resolved after two days and she was transitioned to Humulin R-U-500 at 80 units TID and aspart 40 units every 4-hours for tube feeding coverage but was still hyperglycemic in the 200-300 mg/dl range. Due to autoimmunity and extreme insulin requirements the patient was started on methylprednisolone 20 mg q8hr with improvement of glucose to the 150 to 200 mg/dl range and a decrease in her daily insulin requirements and thus she was transitioned to 60mg of prednisone daily with a 10mg taper weekly. By the time she was discharged 2 weeks later, her glucose was more controlled and her insulin requirements were decreased to aspart 14 units per/meal and detemir 40 units BID. Conclusion: In patients with diabetes mellitus who develop extreme insulin resistance following COVID -19 infection, consider autoimmune etiology in the differential diagnosis, such as insulin inactivating antibodies or insulin receptor blocking antibodies. In our experience laboratory testing of the specific antibodies was not available. Management of autoimmune mediated hyperglycemia will require immunosuppressivetherapy.

Presentation: Thursday, June 15, 2023
THU353 Late Onset Of Immune Checkpoint Inhibitor-Related Diabetes After 3 Years
Authors: Avula Sreekant , Ahmed Ammar , Salim Michael , Anderson Zachary J , Kumar Ameya , Estrada Allison
Published: October 2023

Disclosure: S. Avula: None. A. Ahmed: None. M. Salim: None. Z.J. Anderson: None. A. Kumar: None. A. Estrada: None.

Background: Immune checkpoint inhibitor-induced diabetes mellitus (ICI-DM) is characterized by acute onset of dramatic hyperglycaemia with severe insulin deficiency following exposure to PD-1/PD-L1 inhibitors. The frequency of type 1 diabetes related to ICIs is estimated to be ∼3.5%. Endogenous insulin secretion is depleted within a few weeks of the clinical onset of diabetes. Moreover, the positive rate for islet-related autoantibodies varies from 5% to 50%. Case:  51-year-old male with a PMH of stage 4 adenocarcinoma of the lung with metastasis to brain, bone, and kidneys was sent to the ED for a POC BG above 700 mg/dl. He was diagnosed with stage 4 lung adenocarcinoma three years prior to the current presentation. He received stereotactic radiotherapy for the brain metastases, Carboplatin/pemetrexed/pembrolizumab x4 cycles, then continued maintenance therapy of pemetrexed/pembrolizumab with the last dose given 3 weeks prior. He had recent evidence of progression, so chemotherapy adjustment was planned, and he started dexamethasone 4mg on the day prior to presentation. Upon ED presentation, he reported new onset polyuria and polydipsia for 1 week accompanied by 10% weight loss over the last 3 months. His vitals were stable. Physical examination was unremarkable. Serum glucose level was found to be 726 mg/dl, Bicarbonate level 28 mEq/L (22-30), creatinine 1.99 mg/dl (baseline 1.2), venous blood PH was 7.29, Bicarbonate 24 mEq/L (24-28), anion gap 15 mEq/L (8-16), B-hydroxybutyrate 2.91 mmol/L (0.02-0.27), sodium 127 mEq/L(135-148) and HbA1c 6.3%. He received normal saline boluses and NPH insulin 15 units SQ, after which his repeat BG level was 426 mg/dl. Given prediabetic Hba1c with recent dexamethasone therapy he was thought to have steroid-induced hyperglycaemia. He was discharged on NPH 15 units daily with Novolog sliding scale. Upon clinic follow-up 1 week later, his BGs did not improve significantly despite stopping steroids. His C-peptide level was low at 0.22 ng/ml (1.10-4.40) with BG 443mg/dl, and GAD -65 antibodies were negative. He continued to have hyperglycaemia while on NPH /Novolog regimen, thus he was switched to Lantus and Novolog regimen with better glycaemic control. He continues to have significant insulin requirements 3 months later. Conclusion: Although the mean interval between the first ICI administration and T1DM development was found to be 201 ± 187 days, the development of type 1 DM may occur with longer intervals from initiating the ICI therapy. In our case, the patient developed new-onset diabetes with low C-peptide after 1,095 days from receiving the first dose of pembrolizumab. On the previous case reports, the presence of GAD-65 antibodies is typically associated with shortened intervals between receiving the ICI therapy and the development of DM.

Presentation: Thursday, June 15, 2023
THU370 A Case Of Ketosis-prone Diabetes In A Caucasian Man
Authors: Saeed Zainab , Labib Christine , Trabulsi Maja , Varatharajah Malathy
Published: October 2023

Disclosure: Z. Saeed: None. C. Labib: None. M. Trabulsi: None. M. Varatharajah: None.

Introduction: Ketosis-prone diabetes (KPD) also known as Flatbush diabetes, atypical diabetes and type 1.5 diabetes was first reported in the 1990s in African Americans in the Flatbush neighborhood of Brooklyn, New York. Its exact incidence is still unknown; however, it predominantly affects African American and Hispanic population and is less prevalent in Asians and Caucasians. It presents as diabetic ketoacidosis, a hyperglycemic emergency, in patients with no prior history of diabetes. In addition, it is usually seen in middle-aged, obese patients with a strong family history of Type 2 diabetes mellitus. Here we briefly describe the case of a lean 62-year-old man who presented to the hospital with HHS/DKA and was diagnosed with ketosis-prone diabetes. Case Presentation: 62-year-old man (BMI 21.37 Index) with a past medical history of alcoholic cirrhosis, Crohn’s disease and no personal or family history of diabetes presented to the hospital with complaint of nausea, polyuria and polydipsia. He was found to have hyperosmolar hyperglycemic state with diabetic ketoacidosis. He had a blood glucose of 833 mg/dL (70-110 mg/dL), anion gap of 14, sodium 111 mmol/L (136-145 mmol/L), potassium 7.0 mmol/L (3.5-5.1 mmol/L), creatinine 5.7mg/dL (0.6-1.3 mg/dL), pH 7.26 L (7.35-7.45 pH units), bicarbonate 16 mmol/L (22-34 mmol/L). He was started on an Insulin drip and later transitioned to subcutaneous long and short acting insulin after closure of anion gap. His Hemoglobin A1c was found to be 12.8% (4.8-6.1% A1C, Cpeptide 4.32 ng/mL (0.48-5.05 ng/mL), GAD65 antibody was negative. Four months prior to his hospital admission, his Hemoglobin A1C was 4.9%. Patient was discharged from the hospital on Insulin NPH/Regular 70/30 twice a day and sliding scale with meals. He was followed outpatient in clinic. Within a month of discharge he began to have episodes of symptomatic hypoglycemia, lowest recorded blood sugar was 49. His Insulin NPH/Regular was gradually tapered; he did not require the sliding scale at all. Four months after the episode of HHS/DKA, his repeat hemoglobin A1C was 5.7%. Case Discussion: Despite being known for around three decades now, the exact mechanism of ketosis prone diabetes is still poorly understood. It is thought to be due to insulin resistance as well as severe deficits in insulin secretion. It is classified further based on beta cell function and autoimmunity. In patients with preserved beta cell function and absence of autoimmunity, like our patient, with aggressive management insulin can eventually be discontinued. However, these patients remain at risk of developing diabetes later in life. Our case aims to shed light on the ubiquity of this disease so that physicians can diagnose it promptly and treat accordingly.

Presentation: Thursday, June 15, 2023
THU376 Isotretinoin Related DKA In Type 2 Diabetes
Authors: Radovanovic Natasa , Comi Richard J , Crawford Andrew
Published: October 2023

Disclosure: N. Radovanovic: None. R.J. Comi: None. A. Crawford: None.

Introduction: Isotretinoin is a well-established treatment for acne, known to have a wide variety of adverse effects including hypertriglyceridemia, decreased HDL, and, as per some reports, increased insulin resistance. Rapid worsening of underlying diabetes after treatment with isotretinoin has been described in the literature in patients with type 1 diabetes. Clinical Case: A 45-year-old man was referred to the Endocrinology clinic in February 2022 for an urgent consultation due to rapidly worsening hyperglycemia, acidosis, hypertriglyceridemia and refusal to be evaluated in ED as recommended by his PCP. He was diagnosed with pre-diabetes in April 2021 with an HgbA1c of 6.4% and instructed to make lifestyle changes. He presented 6 months later with HgbA1c of 7.3% and the diagnosis of diabetes prompted him to initiate earlier proposed lifestyle changes. He joined an online weight loss program and was very pleased to achieve a rapid weight loss of 80 lbs within 4 months. Upon initial telephone consultation with the patient, he reported feeling well and refused our recommendations to go to the ED, but agreed to come to our clinic the next day. Upon initial in-person assessment, he denied nausea, vomiting, abdominal pain, or change in mentation but reported polyuria and polydipsia worsening in the months prior. He reported being started on isotretinoin for the treatment of acne 4 months prior. On physical exam, he was mildly tachycardic with stable blood pressure, and signs of dehydration including dry mucous membranes. Labs prior to this visit confirmed hyperglycemia, hypertriglyceridemia, elevated anion gap, low bicarbonate, and elevated ketones concerning for underlying DKA which finally convinced the patient to present to ED where he met the criteria for hospitalization. Isotretinoin was stopped immediately after admission. In spite of a low c-peptide level (0.8 ng/ml) during hospitalization, immunology testing for type 1 diabetes was negative. However, 4 months later a fasting c-peptide increased to a normal level (3.4 ng/ml). Treatment with basal-bolus insulin in the subsequent months markedly improved his diabetes and he was able to achieve HgbA1c of 5.7%. Conclusion: Rapid worsening of diabetes and presentation with DKA is usually associated with a natural course of type 1 diabetes. In the case of our patient who presented with rapid worsening of diabetes, was asymptomatic while in DKA, had negative type 1 diabetes-related antibodies, and presented with marked hypertriglyceridemia. We suspect isotretinoin to be the culprit in the setting of underlining type 2 diabetes. In contrast to reports of isotretinoin increasing insulin resistance, in our case, there was apparently suppression of insulin release. We would like to bring attention to this case with a proposal for close monitoring of the glycemia and lipid levels in patients with underlying diabetes started on isotretinoin.

Presentation: Thursday, June 15, 2023
FRI627 Lost In The Striato-sphere: Diabetic Striatopathy In An Elderly Patient Who Was Lost To Follow-up
Authors: Loughner Chelsea L , Mahmood Ejaz , Sheharyar Ali
Published: October 2023

Disclosure: C.L. Loughner: None. E. Mahmood: None. A. Sheharyar: None.

Introduction: Diabetic striatopathy (DS) represents a spectrum of central nervous system derangements associated with uncontrolled hyperglycemia.1 The most common site of brain involvement is the putamen but can involve any region of the striatal nuclei. The exact mechanism behind DS remains unclear, but current theories postulate hyperosmolarity-related ischemic events that lead to breakdown in the blood-brain barrier and mineral deposition2. We present a case of DS demonstrating a rare neurologic complication resulting from uncontrolled diabetes mellitus. Clinical Case: An 82-year-old female was admitted for workup following new-onset left-sided involuntary jerking movements. On exam, there were choreiform movements in the left upper and lower extremities. Initially, Levetiracetam was started for possible focal motor seizures but with no improvement. MRI brain showed T1 hyperintensity of the right lentiform nucleus, consistent with DS. She had moved recently from out of state and had inconsistent follow-up for type 2 diabetes mellitus for years. Her HbA1c was 13.8%. She was non-compliant with glucose monitoring and insulin therapy. With a comprehensive treatment plan including Haloperidol, physical therapy, improved CGM compliance, and four-times-daily insulin regimen, her chorea improved and resolved completely over a few weeks. Clinical Lesson: DS can present with a variety of neurologic manifestations, including chorea. While choreiform movements can severely impact a patient’s life, they are rarely permanent if treated with either glycemic control or anti-chorea medications. This case highlights the importance to recognize rarer complications of diabetes and the impact of good glycemic control for successful treatment of diabetic striatopathy.

References: 1. Chua CB, Sun CK, Hsu CW, Tai YC, Liang CY, Tsai IT. "Diabetic striatopathy": clinical presentations, controversy, pathogenesis, treatments, and outcomes. Sci Rep. 2020;10(1):1594. Published 2020 Jan 31. doi:10.1038/s41598-020-58555-w 2. Dubey S, Biswas P, Ghosh R, Chatterjee S, Kanti Ray B, Benito-León J. Neuroimaging of Diabetic Striatopathy: More Questions than Answers. Eur Neurol. 2022;85(5):371-376. doi:10.1159/000524936

Presentation: Friday, June 16, 2023
FRI628 Subnormal Fructosamine Levels In Non Diabetic Pregnant Women
Authors: Kabadi Udaya M , Exley Sarah
Published: October 2023

Disclosure: U.M. Kabadi: None. S. Exley: None.

Introduction: American College of Obstetrics and Gynecology (ACOG) and American Diabetes Association (ADA) recommend 2 step testing for diagnosis of Gestational Diabetes (GDM). The process is cumbersome and inconvenient. HbA1c levels are adopted as a screening test in nonpregnant adults but not during pregnancy. Alternatively, serum Fructosamine is not tested for diagnosis of DM in any population. We are in the process of examining utility of serum Fructosamine as a screening test for diagnosis of GDM. However, no data is available regarding Fructosamine concentrations in nondiabetic pregnant women. Therefore, we determined serum Fructosamine levels in pregnant women at 24 to 28 weeks at the time of 1 hour or 3 hour OGTT. Subjects and Methods: Random glucose (mg/dl), Fructosamine ( mcM/l) and HbA1c (%) were determined at 24-30 weeks in 200 pregnant women, age 24-40 years in whom the diagnosis of GDM was eliminated by either normal 1 hour OGTT or by normal 3 hour OGTT in presence of abnormal 1 hour OGTT according to criteria established by ACOG and ADA. 21 age matched nonpregnant women participated as controls. Normal reference ranges for all determinations were established by the local laboratory (Glucose, 60-139; Fructosamine, 200-285; HbA1c, 4.4-5.6). Statistical comparisons between 2 groups were conducted using Student’s ‘t’ test. Results: Fructosamine levels (182 ± 4) were significantly lower (p< 0.01) in non diabetic pregnant women when compared with age matched non pregnant women ( 224 ± 5). Cutoff Fructosamine between groups was 182. Glucose (96 ±7) and HbA1c (5.1 ± 0.2) were not significantly different amongst groups. Conclusion: In non diabetic pregnant women, Serum Fructosamine concentrations are subnormal whereas random glucose and HbA1c levels remain within normal range noted in age matched non pregnant women. Further studies are underway to assess the utility of serum Fructosamine as a screening test in diagnosis of GDM.

Presentation: Friday, June 16, 2023
FRI629 A Mysterious Case Of Mother's Battle With Diabetic Ketoacidosis During Pregnancy
Authors: Sittirat Petchpailin D , Choi Sarah J , Gutierrez Alejandra , Bashyam Mani
Published: October 2023

Disclosure: P.D. Sittirat: None. S.J. Choi: None. A. Gutierrez: None. M. Bashyam: None.

Introduction: Changes in hormone regulatory mechanisms during pregnancy can increase the likelihood of diabetic ketoacidosis (DKA) in pregnant individuals. Despite the increased risk, the likelihood of DKA in pregnant individuals with diabetes mellitus is still low at around 0.5-3%. Management involves aggressive treatment following standard DKA protocols. We delve into a mysterious case of DKA in the second trimester of pregnancy. Case Presentation: A 31-year-old G1P0 woman at 24 weeks gestation with no past medical history presented with nausea, constipation associated with back and abdominal pain. Admission labs were significant for blood glucose 369 mg/dL, CO2 11 meq/L, anion gap 19 mEq/L, white blood cell 17.2 K/uL, HbA1c 9.5%, and serum ketones 3.9 mmol/L. Within 12 hours of admission into the intensive care unit for DKA, the patient was at 5-6 cm cervical dilation without signs of fetal distress. The newborn was delivered prematurely with complications of retinopathy and patent ductus arteriosus. Mother's lab studies showed negative for anti-GAD antibody, insulinoma associated 2 autoantibodies, islet cell antibody, and zinc transporter 8 antibody. C-peptide was low at 0.9 ng/mL (normal range 1.1 to 5.5 ng/mL). The patient was maintained on subcutaneous insulin which eventually tapered off at 2 months post-partum due to hypoglycemia. At 4 and 11-month follow-ups, her HbA1C was 5.8% and 5.5%, respectively. Her blood glucose was well controlled with a regular diet. She did get post-prandial spikes with a high carbohydrate diet. Discussion: Physiological changes in pregnancy make pregnant individuals more susceptible to DKA. Even so, the likelihood of DKA in pregnancy is rare. It is even rarer to have a new diagnosis of diabetes leading to DKA in pregnancy just before evaluation at the standard 28 weeks like the events precipitated in this case. DKA in pregnancy puts both the mother and fetus at risk for long-term complications. The maternal mortality rate in pregnancy with DKA is 5% to 15%, while the fetal mortality rate is 30% to 90%. The patient’s demographic background of being a young Caucasian, thin woman who presented with a new onset DKA and had a low C-peptide was more consistent with type 1 diabetes; however, all her antibodies were normal. It’s questionable if this patient has autoantibody negative new onset type 1 diabetes and is currently in remission. It's worth to mention that she had a history of mild Covid-19 infection at 8 weeks gestation but this new onset DKA developed at 24 weeks gestation. The chance of gestational diabetes was low due to low c-peptide on presentation. Annual follow-up of the patient is necessary to monitor her HbA1C while she is off diabetes medications.

Presentation: Friday, June 16, 2023
FRI630 Information Technology & Decision Support In Electronic Health Records As A Tool To Improve Care For Women With Gestational Diabetes
Authors: Derevianko Olga , Rumyantceva Tatiana , Karseladze Ekaterina , Siyuhova Zaira , Khan Stanislav , Fomin Dmitry
Published: October 2023

Disclosure: O. Derevianko: None. T. Rumyantceva: None. D. Fomin: None.

Background & Aims: The prevalence of gestational diabetes mellitus (GDM) in Russia is increasing and the true prevalence of GDM may be even higher because underreporting of GDM and lack of proper screening. Difficulties in documenting and reaching consensus on the prevalence of GDM exist for a number of reasons, including the use of various diagnostic criteria, past confusion about the specific criteria used to diagnose GDM, and the lack of knowledge about modern recommendations for screening and diagnosis. The aim of our study was to explore the quality of GDM care experienced by women in Russia in Fomin Clinic in 12 cities in Russia and how it could be improved with the help of Electronic Health Record with decision support. Methods: 1264 Electronic Health Records of women with GDM before and after the start of the decision support ( 613 and 651, respectively) were analyzed and rated on a 100-point scale (diagnostics, nutrition, physical activity, self-control of glycemia recommendations were evaluated). The decision support system based on Guidelines of Russian Endocrinology Association, American Diabetes Association, National Institute for Health and Clinical Excellence and Royal College of Obstetricians and Gynaecologists. Results: The average score before using decision support was 47, and after doctors started to use it the average score after 6 months of using became 81. Conclusions: Electronic Health Record with decision support is great tool which improves quality of care for women with gestational diabetes and refines the diagnosis and treatment of GDM in different cities in Russia.

Presentation: Friday, June 16, 2023
FRI631 Insulin Antibody Mediated Extremely Insulin Resistant In Pregnancy
Authors: Liu Zhao , James Deirdre , Dagogo-Jack Samuel
Published: October 2023

Disclosure: Z. Liu: None. D. James: None. S. Dagogo-Jack: None.

Background: Insulin antibodies can rarely complicate diabetes management during pregnancy. Here, we report a patient with extreme insulin resistance during pregnancy associated with positive insulin antibodies. Clinical Case: A 40-year-old primigravida with Type 2 Diabetes (T2DM) was admitted at week 32 for uncontrolled Hypertension (HTN) and extremely high insulin requirement. T2DM was diagnosed 8 years ago and treated with basal insulin 50 units/d, dulaglutide, metformin, and glimepiride. Her HbA1c was 14% one month prior to pregnancy. During pregnancy, patient’s regimen was changed to basal bolus insulin, and oral agents were discontinued. Total daily insulin dose average 740 units (5.6 units/kg/day) at week 32. Patient’s weight was 112 kg at the beginning of pregnancy, increasing to 131 kg in the third trimester. On the high insulin regimen, her HbA1c was 5.6% at week 32. Due to the extreme insulin requirement (indicative of severe insulin resistance), we ordered insulin antibody (IAA), which came back positive at 15 µU/ml (NR <5 µU/ml). Diabetes control remained suboptimal, with frequent post-prandial hyperglycemia followed by hypoglycemia during hospitalization. Insulin regimen was optimized using U-500 in divided doses, starting with 112 units tid. At 34 weeks (hospital day 14), patient underwent cesarean section with delivery of a viable infant (weight 1450 grams, Apgar score 5 and 9 at 1 and 5 minutes). Shortly after delivery, the patient’s insulin requirement plummeted to 62 units daily and she was successfully discharged home. Diabetes control has been stable, with HbA1c ranging between 5.7% and 7% one year after delivery on total insulin dose of 60 units or less per day. Attempts to schedule patient for repeat antibody testing were unsuccessful. Conclusion: Despite the lack of data on repeat antibody testing, this is a compelling case of pregnancy associated extreme insulin resistance likely induced by insulin antibodies. Our conclusion is supported by the dramatic decrease in insulin requirement following postpartum.

Presentation: Friday, June 16, 2023
FRI633 Financial Benefits Of Renal Dose-adjusted Dipeptidyl Peptidase-4 Inhibitors For Patients With Type 2 Diabetes And Chronic Kidney Disease: A Multicenter Study Utilizing Common Data Model
Authors: Jee Choe Hun , Ko Yeh-Hee , Joon Moon Sun , Ahn Chang H , Hwa Ha Kyoung , Lee Hyeongsuk , Hyun Bae Jae , Joon Joo Hyung , Lee Hyejin , Sohn Jang-Wook , Kim Dae-Jung , Gon Kim Sin , Kim Kwangsoo , Min Cho Young
Published: October 2023

Disclosure: H. Choe: None. Y. Ko: None. S. Moon: None. C.H. Ahn: None. K. Ha: None. H. Lee: None. J. Bae: None. H. Joo: None. H. Lee: None. J. Sohn: None. D. Kim: None. S. Kim: None. K. Kim: None. Y. Cho: None.

Objective: To estimate the economic benefit of replacing non-renal dose adjusted (NRDA) dipeptidyl peptidase-4 (DPP4) inhibitors with renal dose adjusted (RDA) DPP4 inhibitors in patients with impaired kidney function and type 2 diabetes. Patients and Methods: This multicenter study analyzed a total of 67,964,996 prescription records of five teaching hospitals in Korea from January 1, 2012 to December 31, 2018 using a common data model. Prescription patterns of NRDA and RDA DPP4 inhibitors were subgrouped based on estimated glomerular filtration rate (eGFR) determined by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Results: NRDA DPP4 inhibitors were more frequently prescribed to patients with impaired kidney function than those with preserved kidney function (25.7%, 51.3%, 64.3%, and 71.6% in patients with eGFR of ≥60, <60, <45, and <30 mL/min/1.73m2, respectively). When applying the prescription pattern of DPP4 inhibitors for patients with preserved kidney function to those with impaired kidney function, cost savings per year were 7.6% for eGFR <60 mL/min/1.73m2 and 30.4% for eGFR <30 mL/min/1.73m2. Assuming patients with impaired kidney function are solely prescribed with RDA DPP4 inhibitors with appropriate dose reduction, 15.4% to 51.2% per year could be saved depending on kidney impairment severity. Conclusion: NRDA DPP4 inhibitors are frequently prescribed in patients with type 2 diabetes and CKD. Prescribing RDA DPP4 inhibitors with doses adjusted to individual kidney function could alleviate the economic burden associated with medical expenditure.

Presentation: Friday, June 16, 2023
FRI659 Diabetes Management: A Retrospective Population-based Study Examining The Association Of Acculturation And Glycemic Control
Authors: Lee Messersmith Andrew , Piervil Esther , Meadows Robyn , Patel Kashyap , Griffin Edward
Published: October 2023

Disclosure: A.L. Messersmith: None. E. Piervil: None. R. Meadows: None. K. Patel: None. E. Griffin: None.

Diabetes disproportionately impacts racial/ethnic minorities. According to 2017-2020 National Health and Nutrition Surveys (NHANES) data, prevalence of diabetes was greater among black non-Hispanic, Asian non-Hispanic, and Hispanic populations compared to white non-Hispanic (Prevalence of Both Diagnosed, 2022). Acculturation, the process by which an individual integrates the attitudes, values, beliefs, and behaviors of a different culture, has also been associated with diabetes (Allen, 2014; O'Brien, 2014). This study incorporates 2013-2018 NHANES data to assess the association between acculturation and diabetes management. Country of birth, years living in the U.S., and primary language spoken at home will serve as proxies for acculturation. This study includes 2,442 individuals who were ever told by a doctor or health professional that they had diabetes (gestational diabetes excluded) with 784 of these participants born outside the U.S. Comparatively 492 individuals with no known history of diabetes had lab results drawn during the NHANES survey supporting newly diagnosed diabetes (A1c ≥6.5), 213 of whom were immigrants. Socioeconomic status and access to health care and health insurance are factors that likely mediate the relationship between acculturation and diabetes control. Initial data analysis found 38% of immigrants with laboratory and/or health professional diagnosed diabetes lived below the poverty level compared to 20% of U.S.-born individuals. Health insurance coverage was 81% among immigrants compared to 92% among U.S.-born individuals. This study will utilize logistic regression to explore the association between acculturation and diabetes. Compliance of individuals living with diabetes to American Diabetes Association screening recommendations will be assessed. Descriptive statistics will be summarized and include demographics, comorbid diseases, body mass index (BMI), cumulative years with diagnosed diabetes, insulin and/or oral antihyperglycemic diabetes therapy, insurance coverage, and frequency of doctor visit(s).

References:

Allen JD, Caspi C, Yang M, Leyva B, Stoddard AM, Tamers S, et al. Pathways between acculturation and health behaviors among residents of low-income housing: The mediating role of social and contextual factors. Social Science & Medicine. 2014 Dec 1;123:26-36.

O’Brien MJ, Alos VA, Davey A, Bueno A, Whitaker RC. Acculturation and the prevalence of diabetes in US Latino Adults, National Health and Nutrition Examination Survey 2007-2010. Prev Chronic Dis. 2014 Oct 9;11:E176.

Prevalence of Both Diagnosed and Undiagnosed Diabetes | Diabetes | CDC [Internet]. 2022 [cited 2022 Dec 28]. Available from: https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html

Presentation: Friday, June 16, 2023