bluuebunny/crossref_metadata_2025 huggingface dataset:
ODP148 GENDER AFFIRMING HORMONE THERAPY AND SPONTANEOUS CORONARY ARTERY DISSECTION
Authors: Yogeswaran Vidhushei , Chang Hou-Hsien , Wright Lorena Alarcon-Casas
Published: November 2022

Introduction

Spontaneous coronary artery dissection (SCAD) is an important and underreported cause of acute coronary syndrome in women. SCAD has been linked to arteriopathy, pregnancy, as well as hormone replacement therapy in cisgender patients. There is a scarcity of data on the long-term cardiovascular effects of gender affirming hormonal therapy (GAHT) with estrogen. Observational studies have shown increased thromboembolic disease and cardiovascular events in transwomen on estrogen, with oral synthetic or oral combined equine estrogens showing a higher association versus transdermal formulations, however there had been no reports of SCAD in transgender patients on GAHT.

Clinical Case

A 37-year old transwoman with a history of gender affirming orchiectomy on GAHT with sublingual estradiol 2 mg BID presented with typical symptoms of acute coronary syndrome. No prior history of chest pain. No personal history or family history of cardiovascular disease or risk factors. Initial Troponin I was 9.52 ng/dl (<0. 04 ng/dl), ECG with non-specific ST-changes. A transthoracic echocardiogram showed hypokinesis of the mid anterior and lateral wall. She underwent urgent cardiac catheterization, found to have SCAD of her ramus intermedius. Given the size of the lesion and wall motion abnormalities, a cutting balloon was used to inflate the lesion, and she remained chest pain free during the hospitalization. She was started on Aspirin, Clopidogrel, and Metoprolol. Sublingual estradiol was determined to be her only predisposing risk factor and therefore it was held during her hospitalization and during the lesion healing period, with plans to change to a constant transdermal estrogen patch in the primary care setting.

Discussion

This is the first case report showing an association of estrogen GAHT and SCAD in a transwoman. SCAD has been observed to occur more often in cisgender women during the late luteal phase and post-partum period, raising the hypothesis that estrogen level fluctuations could potentially play a role. Sublingual estradiol has been shown to have higher peak and trough serum concentration compared to oral estradiol. Research is needed in this area and on the potential adverse cardiovascular effects of GAHT and whether route of estrogen administration plays a role. We support transdermal estradiol in transwomen with or at risk of cardiovascular disease, and close monitoring of serum levels, as well as aggressive treatment of cardiovascular risk factors.

Presentation: No date and time listed
LBODP037 Acute Foot Drop In An Adolescent With Type 1 Diabetes Mellitus At Onset: A Case Report
Authors: Albasri Eman Ebrahim , Al-Sofiani Mohammed E
Published: November 2022

Background

The incidence of type 1 diabetes (T1D) among youth is on the rise worldwide. Diabetic neuropathy is often a late manifestation of diabetes and usually results from the exposure to prolonged hyperglycemia, oxidative and inflammatory stress, and dyslipidemia. Here, we report a case of painless diabetic mononeuropathy as the presenting symptom of T1D that improved shortly after the improvement in glycemic control. Clinical case A previously healthy 15-year-old boy, presented to the emergency department (ED) with left foot weakness and dragging for 1 week. This was preceded by numbness over the left lateral leg and dorsum of the left foot. There was no history of trauma. The patient reported a history of polyuria, polydipsia, and significant weight loss for 3 months, for which he did not seek medical care. There was no family history of diabetes, hereditary neuropathy, or autoimmune diseases. Upon presentation to the ED, a general physical examination was unremarkable with a weight of 60 Kg (BMI= 20 Kg/m2), neurological examination revealed weakness in the dorsiflexion of the left foot (3/5), eversion (4/5), and normal sensation and reflexes. The remainder of the neurological examination including the right foot, upper extremities, cerebellar functions, cranial nerves and monofilament and vibration sensory testing was normal. Fundoscopic exam showed no evidence of retinopathy. The initial laboratory investigations revealed mild DKA (PH 7.28, HCO3 16mmol/L, Na 137 mEq/L, random blood glucose of 306 mg/dl, positive blood ketones) and normal kidney function. A nerve conduction study showed moderate left peroneal motor axonal neuropathy, with normal sensory nerve action potentials. Brain CT scan was unremarkable. Further tests to rule out secondary causes of neuropathy (ANA, B12 level, and thyroid function) were within normal. The diagnosis of diabetes-related mononeuropathy was confirmed by the neurology team and the patient underwent physiotherapy. After the resolution of DKA, the patient continued to use basal/bolus insulin therapy and was discharged home with close follow-up of blood glucose readings. His glycemic control has improved, and the patient reported a significant improvement in the foot drop 3 weeks later. A repeated examination by the neurology team 3 months later confirmed a complete recovery of the left foot drop.

Conclusion

Acute diabetic mononeuropathy can be an unusual presenting feature of T1D and may pose a diagnostic challenge. Although diabetic mononeuropathy is often a late complication of diabetes, our patient presented with acute mononeuropathy at the onset of T1D. This case highlights the importance of early diagnosis and management of diabetes to prevent and sometimes reverse diabetic neuropathy. It also shows that a complete recovery of acute diabetic mononeuropathy can be achieved by improving glycemic control in patients with newly diagnosed T1D.

Presentation: No date and time listed
LBODP055 Discrimination Effectiveness Of Radiofrequency Echographic Multispectrometry As Non Invasive Method For Osteoporosis Diagnosis Applied To Elderly Women With Type 2 Diabetes
Authors: Caffarelli Carla , Pitinca Maria Dea Tomai , Refaie Antonella A , Giglio Elisa , Lombardi Fiorella Anna , Gonnelli Stefano
Published: November 2022

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of fracture, although bone mineral density (BMD) is unaltered or higher in diabetic patients, measured by Dual-energy X-ray absorptiometry (DXA). This paradox could be explained from compromise bone microarchitecture that induce abnormal bone cell function and matrix structure, with increased osteoblast apoptosis, diminished osteoblast differentiation, and enhanced osteoclast-mediated bone resorption.1 In this context, a non-invasive method for assessing the bone density and quality on the axial reference sites (lumbar spine and proximal femur) called Radiofrequency Echographic Multi Spectrometry (REMS), has been introduced and clinically validated. This study aimed to evaluate whether the use of the REMS technique may improve the identification of osteoporosis in T2DM patients. A cohort of ABOUT 100 elderly women with T2DM and mean age 70.5 (± 7.6) years, and 100 healthy age-matched controls underwent DXA and REMS scans on the same anatomical sites (lumbar spine and proximal femur). DXA measurements were all higher in T2DM than controls; instead, all REMS​​ measurements were lower in T2DM than controls. Moreover, the percentage of T2DM women classified as "osteoporotic", on the basis of BMDREMS was markedly higher with respect to those classified by BMDDXA (47. 0% vs 28. 0%, respectively). On the contrary, the percentage of T2DM women classified as osteopenic or normal by BMDDXA was higher with respect by BMDREMS (48.8% and 23.2% vs 38.6% and 14.5%, respectively). T2DM women with fragility fractures presented lower values of both BMDDXA and BMDREMS at the lumbar spine with respect to those without fractures; however, the difference was significant only for BMDREMS (p<0. 05). In conclusion, BMDDXA, as expected, were higher in women with T2DM, while BMDREMS were lower in women with T2DM with respect to controls. Therefore, the data suggest that REMS could be a good diagnostic tool in demonstrating the diabetes-associated bone disease, due to its ability to assess bone quality2 and that may represent a useful approach to enhance the diagnosis of osteoporosis in patients with T2DM.1. Sanches, C. P., et al. The impact of type 2 diabetes on bone metabolism. Diabetol. Metab. Syndr. 9, 1-7 (2017).2. Adami, G. et al. Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: A 5-year follow-up study. Bone 134, 115297 (2020).

Presentation: No date and time listed
LBODP056 Factors That Associate With Under-diagnosing Prediabetes In Primary Care: A Retrospective Study
Authors: Nguyen An V , Nguyen Quoc , Fujioka Ken
Published: November 2022

Diabetes is the leading risk factor for cardiovascular diseases and other comorbidities that significantly reduce the quality of life. Prediabetes is the preceding condition that increases the risk of Type 2 Diabetes Mellitus (T2DM). The Diabetes Prevention Program Outcomes Study (2002-2014) shows that regression from prediabetes to normoglycemic level is associated with a reduction in cardiovascular risk, while such reduction going from diabetes to normal glucose was not statistically significant. As such, it is critical that patients are screened, diagnosed, and counseled for the treatment of prediabetes. This study investigates how well a large hospital system in suburban San Diego, California diagnoses prediabetes and determines if patient demographics could help explain the missed diagnoses. Patient records from five outpatient clinics under Scripps Health who qualified for the diagnosis of prediabetes determined from either more than one fasting blood glucose (FBG) 100-125 mg/dL, or Hemoglobin A1c (HbA1c) 5.7-6.4% between 2018-2020 were reviewed. Factors such as age, race, sex, body mass index (adjusted for different races), and comorbidities were compared between the correctly diagnosed and missed diagnosed. Only 37% of the qualifying patients were diagnosed with prediabetes or impaired fasting blood glucose; of these patients 93% qualified by HbA1c. Of the factors reviewed, overweight and obesity, female sex, Asian race, comorbidities including lipid disorders, and conditions requiring systemic steroids are positively correlated with a correct diagnosis of prediabetes. Factors like male sex, Black/African American race, comorbidities requiring immunosuppressants, antineoplastics, and iron replacements are negatively correlated with a correct diagnosis. This study demonstrates that prediabetes was grossly underdiagnosed, and the diagnosis seems to be made primarily by HbA1c. These data suggest that the convenience of HbA1c and patients’ BMI, race, gender and comorbidities play a role in healthcare providers’ screening for and making the diagnosis of prediabetes.

Presentation: No date and time listed
LBODP060 Abnormal Endothelial Dysfunction Is Already Present Among Individuals With Pre-impaired Glucose Tolerance (Pre-IGT)
Authors: Salmon Jeannine Ann O , Magbuhat Ann Lorraine B , Guerrero-Sali Ruby Jane , Purino Francis Marie C , Macindo John Rey B , Mercado-Asis Leilani Basa
Published: November 2022

Pre-impaired glucose tolerance (pre-IGT) is the stage of compensated hyperinsulinemia and the earliest stage of dysmetabolism in the pathophysiology of type 2 diabetes mellitus (DM). Endothelial dysfunction is a critical pathogenic process for the development of macrovascular and microvascular complications due to uncontrolled hyperglycemia among patients with type 2 diabetes mellitus. In pre-IGT, the main problem is hyperinsulinemia on a background of normal blood sugar. C-peptide, a segment cleaved off from pro-insulin and is equimolar to insulin has been shown to cause intima media thickening when present in increased amount. We hypothesize that in high risk individuals with prolonged hyperinsulinemia, endothelial dysfunction is already present in the prediabetes state. This study was undertaken to determine the following: (1) prevalence of endothelial dysfunction among individuals with pre-IGT and (2) correlation of FMD with levels of blood sugar, serum insulin, HbA1c, BMI, systolic BP and diastolic BP. This is a cross-sectional analytical study of adult patients with risk factors for developing diabetes [first-degree relative with type 2 DM, obesity, history of gestational diabetes, and polycystic ovary syndrome (PCOS)]. Patients diagnosed with pre-IGT underwent brachial artery flow-mediated dilatation. Statistical analysis were conducted using STATA 13.1. Of the 40 high risk individuals, 25 (62.5%) was diagnosed with pre-IGT. Of the 25 individuals with pre-IGT, 19 underwent brachial FMD and abnormal FMD was already demonstrated in four. Although statistically not significant, FMD had positive correlation with 2-hr serum insulin levels and systolic and diastolic blood pressure levels, and no correlation with BMI and blood sugar values. However, as previously shown, the mean 2-hour blood sugar of the individuals with pre-IGT had statistically higher levels than those with normoinsulinemic normoglycemia (NN) (pre-IGT; 107.40 vs. NN; 75 mg/dL, p=0. 001). Our study has shown that as early as the pre-IGT stage, endothelial dysfunction has already developed. This calls for a robust early identification and management of high-risk individuals for type 2 diabetes mellitus.

Presentation: No date and time listed
LBODP062 SGLT2 Inhibition Ameliorates Cognitive And Physical Impairment In Patients With HFpEF And Diabetes
Authors: Mone Pasquale , Lombardi Angela , Frullone Salvatore , Santulli Gaetano
Published: November 2022

Aim

The aim of this study was to assess whether the inhibitor of sodium-glucose cotransporter-2 (SGLT2) empagliflozin improves cognitive impairment in frail older adults with diabetes mellitus (DM) and Heart Failure with Preserved Ejection Fraction (HFpEF).

Methods

We designed a prospective study to assess cognitive and physical function in consecutive frail older adults with DM and HFpEF, comparing the effects of empagliflozin, metformin, and insulin.

Results

A total of 162 frail elders with HFpEF and DM successfully completed the study. The Montreal Cognitive Assessment (MoCA) score was measured at baseline and after 1-month: 19.80±3.77 vs. 22.25±3.27 (p<0. 001) in the empagliflozin group; 19.95±3.81 vs. 20.71±3.56 (p: 0.26) in the metformin group; 19. 00±3.71 vs. 19.1±3.56 (p: 0.81) in the insulin group. A multivariate regression analysis confirmed the beneficial effects of empagliflozin. Additionally, we observed a marked amelioration of physical impairment, assessed by the 5-meter gait speed test, in the empagliflozin and in the metformin arms, but not in patients receiving insulin.

Conclusions

To the best of our knowledge, this is the first study to show significant beneficial effects of empagliflozin treatment on cognitive and physical impairment in frail subjects with HFpEF and DM.

Presentation: No date and time listed
LBSUN152 The Warburg Effect And Complex Thermomics Inform Phenotypic Expression
Authors: Fredericks Robert S
Published: November 2022

Introduction

As technology reveals biological complexity, integration of vast clinical and multi-omic data utilizing artificial intelligence promises to clarify confusion. We have utilized challenge tests to inform algorithmic graphs recognizing heat as foundational for understanding phenotypic variation. Thermomics, describing complex thermic influences that are difficult to objectively quantify thereby compromising application to AI, are readily included in practice-derived models.

Methods

For the past 45 years cases have been evaluated with oral calcium challenge and immersion in water while observing changes in urinary composition. Between 2001 and 2010 respiratory gas exchange following a high carbohydrate meal combined with pulsatile insulin revealed metabolic variance that combined with basic, translational and clinical data of others informed generation of algorithmic graphs. COVID 19 served to clarify the effect of ACE2 disruption by predicting divergent phenotypic expression mediated by calciotropic hormones.

Results

Extraction of O2 from glucose, a consequence of fatty acid synthesis producing R/Q > 1 is modeled as foundational for metabolic evolution. This Warburg effect, recognized in proliferating malignant cells, was observed at the systemic level in humans and, modeled as mediated by hypoxia inducible factors regulating glucose uptake and suppression of beta-oxidation. Higher order orchestration is governed by a signaling structure including PTH, PTHrP, FGF23, Klotho, prolactin, growth hormone, IGFs, insulin, SGLT2, thyroid, adrenal and vit D while salt inducible kinase contributes to understanding of terrestrial adaptation. Inclusion of thermomics leads to prediction of a favorable effect of sub-cutaneous adipose beiging on CNS function mediated by circulating Klotho as a constraint on FGF23 in amelioration of Long COVID by phentermine that is also effective in hypophosphatasia where the exercise induced beiging, induced by irisin is known to be dependent upon alkaline phosphatase. The post-exertional malaise of Myalgic Encephalomyelitis, where exercise induces elevation in R/Q and reduced work capacity, has informed modeling of the systemic Warburg effect. The models are further validated with mechanistic explanation for recent reports of marked increases of R/Q in human Paget's disease and CEBPb expression dependence mimicking Alzheimer's and limiting life span in mice.

Conclusions

The value of practice is demonstrated by the ability to model thermomics even when difficult to quantify. The work is validated by explanation of old conundrums, discovery of treatment for unresolved problems, facilitation of case-based discovery and integration of emerging data from basic sciences. The Warburg effect when recognized as foundational to biology, contributes to a General Theory of Metabolism applicable to effective personalization of care.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
LBSUN291 Fournier's Gangrene In A Diabetic Male Taking Dapagliflozin
Authors: Patel Janki M , Shah Parth , Shah Love S
Published: November 2022

Background

Fournier's gangrene (FG) is a form of necrotizing fasciitis characterized by polymicrobial infection of the perineal, perianal or genital areas; risk factors include diabetes mellitus and male gender. Dapagliflozin is one of four sodium-glucose cotransporter 2 (SGLT2) inhibitors FDA-approved for the treatment of Type 2 diabetes mellitus (T2DM). SGLT2 inhibitors decrease serum glucose and increase glycosuria by binding to renal tubular SGLT2 receptors, and inhibiting reabsorption of glucose from urine in the proximal convoluted tubule. Since their introduction in 2013, SGLT2 inhibitors have been shown to protect against decline in GFR, to improve LVEF in HFrEF, and to improve survival in T2DM. However, due to associated glycosuria, SGLT2 inhibitors are commonly associated with candidiasis, and are rarely associated with life-threatening adverse effects including FG, and euglycemic diabetic ketoacidosis. | Clinical case: A 57-year-old male with T2DM, diabetic neuropathy and hypertension presented to the ED with left testicular swelling, penile discharge and dysuria of several days duration. He was afebrile and vital signs were in normal ranges. Examination disclosed left-sided scrotal swelling surrounding a 1 cm black eschar, induration, erythema and discharge. WBC 15.1 with 79% neutrophils and HbA1c 10.4%. Dapagliflozin 4 mg daily had been added to insulin degludec one month earlier. He denied previous history of scrotal/genital infections. Ultrasound of the scrotum showed wall thickening on the left, a small hydrocele and heterogenous echogenicity suggesting an abscess. Pelvic CT scan with contrast revealed multiple small air bubbles in the scrotal wall. Findings were consistent with FG. He was treated promptly with IV piperacillin / tazobactam and vancomycin. Urological debridement of necrotic scrotal skin was carried out the morning after admission; cultures obtained at surgery grew Gram neg rods and Diphtheroids. Tissues within the scrotum were not gangrenous. Primary closure with a Penrose drain was attempted, but the skin surrounding the sutures necrosed and a second urological procedure was done to remove the sutures and allow the scrotal wall to heal by secondary intention. He was discharged after 5 days and I. V. ampicillin/sulbactam was continued for a total of 14 days with resolution of infection and healing of the skin.

Conclusion

SGLT2 inhibitors decrease mortality and increase quality of life in T2DM compared to older treatments with exogenous insulin and its secretagogues. Optimal utilization of SGLT2 inhibitors in the management of patients with T2DM will entail 1) quantifying risk specifically attributable to SGLT2 inhibitors since T2DM is a known risk factor for FG, and 2) routinely informing/reminding patients with T2DM to promptly report skin infections of the groin, perineum or perianal region.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
LBSUN309 The Effect Of Prebiotics In Newly Diagnosed Youth With Type 1 Diabetes (T1D)
Authors: Ismail Heba , Evans-Molina Carmella , DiMeglio Linda A
Published: November 2022

Acetylated and butyrylated high amylose starch (HAMS-AB) is a prebiotic that is effective in T1D prevention in mouse models. It alters the gut microbiome profile towards bacterial fermenters with increases short chain fatty acids (SCFA) production which improves glycemia, insulin sensitivity and secretion. The objective of this pilot study is to assess the effect of oral HAMS-AB for 4 weeks on glycemia, microbial metabolite and SCFA production in newly diagnosed (<2 years of diagnosis) youth with T1D. Thus far, we have enrolled 7 subjects with 1 early drop out due to nausea secondary to the prebiotic. The mean±SD age in the remaining 6 was 14.4±1.8 yrs, diabetes duration 18.6±6.3 months, 4/6 were female and White, all with BMI of <85th%. The prebiotic was safe and well-tolerated in all 6 who remained in the study. We assessed glycemia changes pre and post-intervention and the percent time in range (TIR) from continuous glucose monitoring data over a 4 week period increased significantly: 61. 0% vs. 71.8%, X2 18.2, p=0. 001. Stool SCFA levels were measured in 4 subjects, and butyrate levels increased post-prebiotic (8.1±9.8 vs 22.6± 6.4mmol SCFA/kg fecal material, p=0. 047). Serum and plasma Hippurate levels (a microbial metabolite associated with increased gut bacterial diversity and improved glycemia) increased significantly after 4 weeks of prebiotic consumption compared to before in all 6 individuals (p=0. 028 for serum and p=0. 033 for plasma, respectively). In summary, the prebiotic HAMS-AB was safe in adolescents with T1D. It significantly increased the percent TIR, serum and plasma Hippurate levels and stool butyrate levels. Enrollment continues as collection of samples from more participants should allow for a more conclusive analysis.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
ODP612 Inverse Association Between Healthy Diet Status and Non-Alcoholic Fatty Liver Disease Among Patients With Diabetes Mellitus
Authors: Gu Xiao , Hu Xiang , Zhang Xingxing , Yang Lijuan , Zheng Yinfeng , Zhou Jingzong , Du Linjia , He Zhiying , Yang Bo , Gu Xuejiang
Published: November 2022

Objective

Aimed to investigate the associations between healthy diet status and non-alcoholic fatty liver disease (NAFLD) among patients with diabetes mellitus.

Methods

This study enrolled 2,404 participants (1,504 males and 900 females; mean age 50.18 ± 12. 06). Healthy diet status was defined based on the number of healthy diet scores and classified into three categories. Multivariate-adjusted logistic regression analyses were performed to explore the association between healthy diet status and NAFLD, presented by odds ratio (OR) with 95% confidence intervals (CI).

Results

Participants with the most healthy diet had a lower odds of NAFLD than those with the least healthy diet (OR: 0.66, 95% CI: 0.50,0.88, P = 0. 004), no significant interactions were showed between healthy diet status and strata (gender, age, diabetes duration, metabolic status). Linear regression analyses showed the most healthy diet was negatively associated with FLI (β: -4.70, 95% CI: -7.61, -1.79, P = 0. 002).

Conclusions

The most healthy diet was independently and inversely associated with NAFLD prevalence and FLI among Chinese patients with diabetes mellitus.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
ODP199 Full Implementation of Automated Self-Adjusting Subcutaneous Insulin Algorithm
Authors: Mehta Paras , Kohn Michael , Rov-Ikpah Esther , Luis Craig San , Johnson Craig , Rushakoff Robert
Published: November 2022

Background

- We programmed a self-adjusting subcutaneous insulin algorithm (SQIA) in the electronic medical record for patients who are NPO, on total parenteral nutrition (TPN), or on continuous tube feedings (CTF). The SQIA only requires a nurse to enter a patient's current glucose value and then calculates the next insulin dose based on previous dose, and current and previous glucoses. The SQIA titrates for a goal glucose of 120 -180 mg/dL. The advantage of this automated algorithm is that no new orders are required, even if insulin is added to TPN or tube feeding rate is changed. We previously reported results of a pilot study with 67% of blood glucoses in the 80-180 mg/dL range without any hypoglycemia (glucose < 60 mg/dL).

Hypothesis

- Following the successful pilot, the SQIA was instituted in September 2020 at our institution's three adult hospitals. We hypothesized that glucose control with the SQIA will be non-inferior to previous inpatient glycemic management and successfully maintain blood glucoses in the goal range.

Methods

- The SQIA was implemented on September 3, 2020 for patients who were NPO, on TPN, or on CTF. Any clinician placing insulin orders could select the SQIA as an alternate to ordering standard fixed aspart dosing or a sliding scale at four-hour intervals. We performed a prospective analysis on all patients managed with the SQIA during the first year of implementation (9/3/2020–9/2/2021) to evaluate use of the SQIA and resulting glycemic control. Results were compared to patients during the preceding one-year period (9/3/2019-9/2/2020) who were ordered for standard subcutaneous insulin aspart dosing while being NPO, on TPN, or on CTF.

Results

During the study period, the SQIA was utilized during 2691 time intervals within 1774 hospitalizations. The average duration for each interval was 56.4 hours and glucoses were checked every 3.9 hours while on the SQIA. Average point-of-care blood glucose while on SQIA was 157.5 ± 52.6 mg/dL. In a similar set of 1987 hospitalized patients in the preceding year who were on standard subcutaneous insulin orders, the average blood glucose was 159.4 ± 55.1 mg/dL.

Conclusions

- A self-adjusting SQIA effectively maintained glucose within the goal inpatient range during our first year of implementation and was non-inferior to prior glycemic control using standard dosing protocols. The SQIA provided an avenue for effective glycemic control while eliminating the need for insulin dosage titration by clinicians. Hospitals and health systems should consider pursuing similar innovations to improve the ease of inpatient glycemic control while continuing to meet glycemic targets.

Presentation: No date and time listed
ODP227 Nivolumab Induced Type 1 Diabetes
Authors: Lim Jonea , O’neal Katherine , Henderson Jeffrey , Skaggs Joanne
Published: November 2022

Introduction

Nivolumab is a treatment option used for renal cell carcinoma (RCC). It is reported to have high response rate to renal cancer cells with rare adverse events to the endocrine system including type 1 diabetes mellitus (DM1). Our case reports the use of nivolumab and ipilimumab in a patient with RCC with timeline of hyperglycemia following initiation of the regimen.

Clinical Case

A 71-year-old woman with RCC metastasized to the lungs experienced adverse effects leading discontinued sunitinib therapy. Her imaging showed increased pulmonary nodules with tumor extension into left superior and inferior pulmonary veins. Therapy with Ipilimumab 56 mg plus nivolumab 169 mg initiated shortly. Pre-treatment labs were within normal limits. Labs remained within normal limits (plasma glucose 82 mg/dL) before second treatment. Less than a week following 2 nd treatment, she presented with generalized rash and was sent to the emergency room (ER). She was treated with one dose IV and a course of PO steroids for total 5 days. Infusions were put on hold. Despite rash resolving, she continued to have low-grade fever (99.1°F). She also reported 10 lbs. weight loss and polydipsia. Three weeks follow-up lab noted plasma glucose level of 559 mg/dL. She was instructed to go to the ER. ER labs: HbA1c: 9.1%,, plasma glucose 525 mg/dL, B-hydroxybutyrate 10.47 mmol/L; UA 3+ glucose; 2+ ketones. She met criteria for diabetes ketoacidosis (DKA). She was admitted, started and later discharged on insulin therapy with referral to see outpatient diabetes providers. Labs obtained during outpatient follow up include: C-peptide 0.3 ng/ml & paired plasma glucose of 246 mg/dl. Nivolumab monotherapy re-initiated later. With insulin therapy, HbA1c improved with most recent HbA1c at 7.7%. Clinical Lesson: There is evidence of anti-PD-1-monoclonal-antibody-induced diabetes mellitus throughreduced activity of PD-1 which is common to both traditional onset type 1 diabetes or antiPD-1 therapy-related diabetes. PD-1 reduction may cause inappropriate activation of T cells causing autoimmune response against pancreatic beta cells. Clotman et al reports 42 cases of PD-1 inhibitor–induced DM1. Half of tested case subjects (22/39 or 56%) had detectable diabetes-related autoantibodies; however, no clear pattern of diabetes-related autoantibodies. Additionally, median interval from immunotherapy initiation to diagnosis of diabetes was 5 weeks in GADA-positive subjects vs 9 weeks in GADA negative subjects. Li Zhang et al reports 735 cases of immune checkpoint inhibitors (ICI) DM: 25% presented fulminant DM1; 45% presented in DKA. Of these, 25% had severe case and 5.5% resulted in deaths. Because immunotherapy use will continue to increase, raising awareness of ICI DM induced by anti–PD-1 therapy is essential. Although incident is rare, missing or delaying diagnosis can not only significantly impact a patient's life but be potentially life-threatening.

Presentation: No date and time listed
ODP228 Obesity Induced a Down-Regulation of nNOS in Intrapancreatic Nervous System
Authors: Huang Zhihui , Wang Yiqiao , Chen Meiling , Sha Prof Lei
Published: November 2022

Objective

Obesity has become a serious global public health problem. Obesity is frequently preceding and the most important risk factor of type 2 diabetes. Pancreas regulates glucose metabolism and glucose homeostasis, and abnormality of pancreas play an important role in insulin resistance and diabetes. Intrapancreatic nerve innervation modulates insulin release and is tightly linked to the onset and development of diabetes. However, it is not known whether the activity of the intrapancreatic nervous system has been altered before the onset of diabetes. In this study, we examined the intrapancreatic nervous system in rats with obesity looking for the changes induced by obesity.

Methods

Obese Sprague-Dawley rats were developed with feeding high fat diet for 10 weeks. Using Immunofluorescence method, choline acetyl transferase (ChAT) and nNOS positive neurons in intrapancreatic ganglia were counted. ChAT and nNOS expression in pancreas were also measured with western blot method.

Results

(1) There was no significant difference in fasting blood glucose between obese rats and normal rats, but oral glucose tolerance test showed that the oral glucose tolerance was impaired in obese rats. (2) In rats fed with normal diet, 80.2%±1.5 neurons in intrapancreatic ganglia were ChAT positive, and in the obese rats, 79.3%±1.8 neurons were ChAT positive. There was no significant difference between the two groups (p>0. 05, n=5). In intrapancreatic ganglia of obese rats, 40%±1.4 neurons were nNOS positive, which was significantly lower than that (60.5%±1.2) of rats fed with normal diet (p<0. 01,n=5). (3) In pancreatic tissue, the relative expression level of ChAT protein was 1. 02±0. 03 in rats fed with normal diet and 0.98±0. 05 in obese rats (p>0. 05, n=5). The relative expression level of nNOS protein was 1.70±0. 08 in normal rats and 1.10±0. 05 in obese rats (p>0. 01, n=5).

Conclusion

The cholinergic nerves in intrapancreatic nervous system was not altered in obese rats, however, nNOS nerves was down-regulated in obese rats. The down-regulation of nNOS would induce a hyperactivity in intrapancreatic nervous system and this would cause an enhancement of insulin release, which has been observed in obese individuals.

Presentation: No date and time listed
ODP245 Syndrome of Diabetic Ketoalkalosis due to Severe Hypercortisolemia: A Case Series
Authors: Uwaifo Gabriel , Varughese Amy G
Published: November 2022

Introduction

Decompensated diabetes (DM) precoma/comas states are major causes of hospital morbidity and mortality. These commonly include diabetic ketoacidosis (DKA), diabetic hyperglycemic hyperosmolar syndrome (DHHS), diabetic hypoglycemia coma (DHC) and diabetic lactic acidosis (DLA). Another less common decompensated DM precoma/coma state to be aware of is Diabetic ketoalkalosis (DKAL). We present two cases of DKAL due to severe hypercortisolemia (HCS) from ectopic Cushing's syndrome (ECS). Clinical cases; Case 1 was a 61 yr old AA woman with suboptimally managed type 2 DM who had been admitted for DKA 2 months before. She had marked hyperglycemia (blood glucose >500mg/dl) on repeated measures (RMs) and chronic diarrhea with tachypnea and altered mental status (AMS). She had heavy tobacco abuse and work up revealed a right lung mass biopsy of which showed a malignant neuroendocrine tumor presumed to be malignant bronchial carcinoid. Her initial lab tests showed marked metabolic alkalosis with severe hypokalemia and elevated anion gap, ketonemia and ketonuria. Presentation was typical of DKAL and subsequent work up showed ECS with serum cortisol > 110 (n; 4.3-22.4ug/dl) on RMs and serum ACTH 377-480 (n; 0/46pg/ml). Her metabolic derangements were corrected and HCS managed with mild impact using ketaconazole and octreotide but she died within a month of admission with intractable septic shock despite parenteral antimicrobials. Case 2 was a 46 yr old Hispanic man with heavy tobacco abuse admitted on account of AMS, tachypnea and upper abdominal pain. He had severe hyperglycemia (blood glucose >750mg/dl on RMs) though not known to have DM. HBA1c was > 15% indicating undiagnosed DM. Initial lab tests showed marked respiratory and metabolic alkalosis, marked hyponatremia, hypokalemia, hypo-osmolality but with ketonemia and ketonuria. Presentation was consistent with DKAL. Work up showed a left lung lesion with pleural effusion shown to be small cell carcinoma of the lung. He was also found to have profound HCS (serum cortisol >150ug/d; on RMs) confirmed due to ECS with serum ACTH, 1500-1800pg/ml. Metabolic derangements were corrected and he was started on ketoconazole and etomidate to correct HCS with little response. Elective bilateral adrenalectomy was planned but patient abruptly discharged himself AMA. He was readmitted ∼ 3 weeks later with a massive pulmonary embolism and acute respiratory failure from which he never recovered. He died ∼ 2 months later.

Discussion + Conclusions

DKAL is an uncommon but important potential acute presentation of decompensated DM. Early recognition and management requires close attention to the acid-base and electrolyte derangements that often accompany it. Among the many possible causes of DKAL severe HCS is an important possibility to be consider. Rapid diagnosis and institution of aggressive therapy of HCS is crucial as it often has high morbidity and mortality potential.

Presentation: No date and time listed
ODP249 The Effects of Rice From Starch-removing Rice Cooker on Postprandial Glucose And Insulin Levels in Healthy Adults: A Randomized, Double-blind, Crossover Study
Authors: Bhekasuta Apanaree , Siriwan Chonpiti
Published: November 2022

Background

The starch-removing rice cooker (SRR) is an innovative kitchen appliance which uses multiple water drainage techniques passing the rice to reduce starch from rice. Many manufacturers claimed their success in starch reduction from the rice. We hypothesized that the rice from SRR cooker might have a lower postprandial glucose than normal rice cooker.

Objective

To assess acute glycemic and insulin responses after ingesting rice from SRR versus normal rice cooker in healthy adults.

Material and Methods

We conducted a first pilot randomized crossover study to compare the postprandial glucose and insulin levels between rice from SRR versus normal rice cooker in healthy adults. This randomized crossover study was done in healthy volunteers aged 18 years and older. The participants were instructed to ingest 150 grams of rice which were randomly assigned to ingest rice from SRR or rice from normal rice cooker. Plasma glucose and insulin measurements were taken at 30, 60 and 120 minutes. After 1 week, the participants were cross over to another rice and plasma glucose and insulin levels were obtained as the same. The other metabolic parameters, satisfaction score and fullness were recorded to compare between SRR and normal rice.

Results

Plasma glucose at 30 minutes was significantly lower in the SRR group compared with the control group (120.45 ± 14.48 vs 137.27 ± 22.21; p <0. 05). And Likewise, Plasma glucose at 60 minutes was also significantly lower in the SRR group compared with the control group (110.82 ± 18. 08, 122.64 ± 21. 08; p <0. 05). However, There is no statistically significant difference in insulin and triglyceride levels between the SRR and control groups. Furthermore, there was no significant difference in appetite survey between SRR and control groups.

Conclusion

Lower post prandial glucose has been observed in rice from SRR compared with normal rice in healthy volunteers Keyword: starch-removing rice cooker, Type 2 diabetes, rice consumption, postprandial glucose

Presentation: No date and time listed
ODP250 The Role of Urine Renal Injury Markers in Obese Children and Adolescents with Diabetes Mellitus
Authors: Bae Ahn Moon , Suh Jin-Soon , Cho Kyoung Soon
Published: November 2022

Backgrounds

Diabetic children especially who are obese lead to poor glycemic control thus are at higher risk for early microvascular complications. Renal tubulointerstitial markers play integral role in the evaluation of diabetic nephropathy and various biomarkers have been proposed. Yet, their role in obese pediatric population is uncertain. The aim of this study is to investigate renal injury markers in children with diabetes mellitus (DM) in relation with obesity and determine their role for early predictor of diabetic complications.

Methods

Fifty-three children and adolescents diagnosed with either type 1 or 2 DM and 44 controls aged 7-18 years were included. Clinical and laboratory characteristics including renal injury markers among subjects were compared with respective to body mass index (BMI), presence and type of DM.

Results

Urine neutrophil gelatinase associated lipocalin and kidney injury molecule-1 were lower whereas beta-2 microglobulin and n-acetylglucosamine (NAG) concentrations were higher in controls compared to diabetic children. None of renal injury markers showed significant difference between normoweight and obese children. In multiple regression analyses, urine NAG was associated with HbA1c and the presence of DM while high homeostatic model assessment of insulin resistance was identified as a risk factor of for increased urine NAG in type 2 diabetic children.

Conclusion

Urine NAG could be a marker associated not only with diabetic nephropathy, but also with insulin resistance regardless of BMI.

Presentation: No date and time listed
ODP260 New Type of Autoimmune Diabetes
Authors: Kumar Surina , Sargis Robert , Syed Uzma
Published: November 2022

Immune checkpoint inhibitors (ICIs) are an emerging therapy that has revolutionized the management of certain cancers. Data on long-term side effects of these drugs are now showing a risk for development of new endocrinopathies. In this case report, a patient with new Type I diabetes (DMI) is discussed. The patient is a 67 year old male with past medical history of metastatic renal cell carcinoma with multiple recurrences of disease. A brief review of the patient's oncologic history revealed multiple surgeries, including complete nephrectomy, multiple drugs, including ICIs, and radiation therapy. Over the course of his treatment, he received Nivolumab (anti-PD1 agent) for 5 cycles with HbA1c increased from 5.4% to 6.9% from pre-treatment to post-treatment, but the HbA1c improved to 5.8% one year after drug cessation. Later he was started on Pembrolizumab (anti-PD1) and has had 10 cycles of therapy to date. Random blood glucose frequently exceeded 200 after start of pembrolizumab therapy. Ipilimumab (anti CTLA-4) was started in combination with pembrolizumab six months later, but it was held after the second cycle due to development of diabetes with HbA1c of 11.1%. He was also found to have persistent, severe hyperglycemia noted during routine bloodwork. Autoimmune DM was confirmed with a positive glutamic acid decarboxylase antibody (GAD65) of 8 nmol/L. Consequently, the patient had multiple hospital admissions for glucose exceeding 400. His condition was exacerbated by the fact that he had difficulty coming to terms with his diagnosis, and he was noncompliant with medication. At that time, the patient stated that he had not done anything wrong and did not understand why this had happened to him. He was resistant to starting therapy and had difficulty understanding insulin dosing, blood glucose monitoring, and the consequences of hyperglycemia/hypoglycemia. After extensive education during a 2 week hospitalization, the patient was eventually place on an appropriate dose of basal-bolus insulin therapy and is currently doing well. It is important to note some emerging challenges to treating this new population of patients with DM1 due to ICI therapy. Firstly, many patients in this scenario live alone and have poor support systems. They have difficulty learning new technology (glucometer, insulin pen, etc.) and self adjusting medication (sliding scale). Older patients can also be more resistance to change in diet and lifestyle. They may have pre-existing insulin resistance that makes initial insulin dosage difficult. Finally, noncompliance is dangerous due to risk of hypoglycemia, diabetic ketoacidosis, and exacerbation of other comorbidities. Clinicians should also consider the patient's psychosocial ability to understand and manage this condition.

Presentation: No date and time listed
ODP565 Success of CME at Improving Knowledge and Confidence Related to CGM Use in Patients with T2D
Authors: LaCouture Michael , Larkin Amy , Le Anne
Published: November 2022

Introduction

We sought to determine if an online continuing medical education (CME) activity could improve knowledge and competence of diabetologists/endocrinologists (D/Es) and primary care physicians (PCPs) related to interpreting and applying ambulatory glucose profile (AGP) data to patient management regimens for type 2 diabetes (T2D).

Methods

Education design included a “test, then teach” approach to elicit cognitive dissonance, with evidence-based feedback provided following each learner response. The activity launched May 11, 2021, and data were collected through August 12, 2021.

Results

Matched learner data indicate that overall, 29% D/Es learners’ responses and 36% of PCPs learners’ responses improved from pre-to-post.

Conclusions

This study demonstrates the success of interactive, case-based, online CME on improving competence and confidence of D/Es and PCPs, related to interpretation and application of AGP data. Case-based education with interactive polling questions and detailed explanations related to best choices should be employed more often to help clinicians apply knowledge/data into practice to improve patient management and care.

Presentation: No date and time listed
ODP567 Success of CME at Improving Knowledge and Confidence Related to Hyperglycemia Associated with Cushing Disease and Acromegaly
Authors: Carothers Ann , Larkin Amy , Maeglin John
Published: November 2022

Introduction

We sought to determine if an online continuing medical education (CME) activity could improve knowledge and confidence of primary care physicians (PCPs) and endocrinologists (endos) related to hyperglycemia associated with cushing disease (CD) and acromegaly.

Methods

The effect of an online, 30-minute, CME-certified roundtable discussion among 3 faculty was analyzed to determine efficacy. The activity posted April 29, 2021, and data were collected through July 7, 2021.

Results

Overall, 51% of PCP learners and 55% of endo learners improved their knowledge.

Conclusions

This study demonstrates the success of an online, 30-minute roundtable discussion on improving knowledge and confidence regarding hyperglycemia associated with CD or acromegaly, with gaps identified for future education.

Presentation: No date and time listed
ODP620 A Cross-over Trial Using Insulin Glargine And Neutral Protamine Hagedorn Insulin For The Poorly Controlled Patients With Type 2 Diabetes Who Refused Multiple Daily Insulin Injections
Authors: Odhaib Samih Abed , Alibrahim Nassar Taha Y , Ayad Alidrisi Haider , Mansour Abbas Ali
Published: November 2022

A Cross-Over Trial Using Insulin Glargine and Neutral Protamine Hagedorn insulin for the Poorly Controlled Patients with Type 2 Diabetes Who Refused Multiple Daily Insulin Injections Background: Data in the literature describing the comparison between Neutral Protamine Insulin of Hagedorn (NPH) and glargine insulins are conflicting. While some studies revealed the superiority of Glargine, others had shown comparable results and even NPH superiority figures. We have many patients on NPH basal therapy in our clinical practice and another good number on Glargine. We did observe adverse effects in both groups, but local data and real numbers comparing both regimens are lacking.

Objective

To compare basal insulin regimen using NPH or Glargine in efficacy, hypoglycaemic events, and weight gain. Design and setting: A prospective interventional crossover study was conducted in Faiha Specialized Diabetes, Endocrine and Metabolism Center from 2018 through 2021, involving patients less than 65 years old with uncontrolled Type 2 Diabetes Mellitus whose HbA1c >10% on oral antidiabetic drugs (OAD); randomized into two groups (G1 & G2), 70 patients in each group had completed the study, one group received NPH and the other received Glargine in addition to their OAD for one year, then they were crossed over for another one year after a period of washout.

Results

The mean age was 48.9±5.5 and 45.9±4.1 years for G1 and G2, respectively. 36(51.4%) in G1 were women versus 27(38.6%) in G2. In the first phase of the study, HbA1c reduction was 5.5±1.1% for the NPH group and 5.3±1.1% for the Glargine group (p=0.418), there was 1.7±2.7 versus 1.1±2.9 Kg weight gain (p=0.209), 27(39.7%) hypoglycemic event versus 26(37.7%) (p=0.883) and 5 patients(7.4%) achieved HbA1c <7% versus 8(11.6%) (p=0.397) for the patients in NPH and Glargine groups respectively. While in the crossover phase, the data comparing Glargine and NPH groups are as following: 0.6±0.8 versus 0.5±0.9% reduction in HbA1c (p=0.413), 1.7±3.1 versus 0.6±2.2 Kg weight loss (p=0. 035) although the final weight was not much different 77.3±12. 0 versus 77.7±11.5 (p=0.841), 16(27.1%) versus 23(36.5%) hypoglycemic events (p=0.493) and 17(29.8%) versus 11(17.7%) achieved HbA1c<7% (p=0.121) respectively.

Conclusion

In our study, there was no significant difference in HbA1c reduction, Hypoglycemic events, and weight gain between patients using NPH or Glargine basal insulin regimen. Keywords: Diabetes; Glargine; NPH.

Presentation: No date and time listed