bluuebunny/crossref_metadata_2025_split huggingface dataset:
Incidence of Diabetic Ketoacidosis in Hospitalized COVID19 Patients With Type 2 Diabetes
Authors: Almistehi Wael Mohammad , Alturki Abdulrahman Mohammed , Bukhari Bashear Adnan 
Published: May 2021

Abstract
Introduction: Diabetes is a disease of persistent hyperglycemia with a devastating complication and even death if left untreated. Morbidity and mortality often increased for any condition among patients with diabetes. Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes. It can occur to type 2 diabetes (T2DM) under severe stress. Since the pandemic of Coronavirus disease 2019 (COVID19), that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, Hubei China, in December 2019, more than 47 million infected cases reported leading to more than 1.2 million deaths reported worldwide. The presence of diabetes in COVID19 patients had a higher odd of severity and mortality of the COVID19 compared to patients without diabetes. Our study aims to identify the incidence rate of DKA in T2DM admitted with COVID19 in a tertiary care center. Evidence showed those populations at considerable risk for morbidity and mortality and no available data in Saudi Arabia. Method: A retrospective cohort of adult patients admitted for COVID19, with a diagnosis of T2DM or clinical evidence of DKA in a tertiary care center named King Fahad Medical City located in Riyadh in Saudi Arabia. The study involved a chart review. Data collected from the beginning of March 2020 till the end of June 2020. Results: Of 244 patients with T2DM admitted for COVID19, 190 patients were male, and 55 patients were female. The mean age was 59-year-old. out of 244 patients collected, 20 had developed DKA. The incidence rate of DKA was 8%. Number and percentage of male was 15 (71.4%) and female 6 (28.6%). Out of 20 patients admitted with DKA and COVID-19, two patients were not known to have diabetes prior to the presentation. Mortality resulted in 5 out of 20 during admission stay, represent 25% of all patients with DKA. Discussion: Here we report the first study in S.A. about DKA incidence in T2DM with COVID19 pneumonia. In the present study, an alarming observation of a higher incidence of DKA in a patient with type 2 diabetes and COVID19 infection as incidence reaches 8% over a short period of time while incidence worldwide area range was less than 2 per 1000 person-year for DKA in type 2 diabetes without COVID19. A study reported 20 % of patients who have diabetes and COVID19 presented ketosis developed DKA. We report the incidence of DKA in selected group. The mortality rate was not far from different evidence in the world. The mortality rate was 25% in the present study. In the USA, it reaches 30% of inpatient with hyperglycemia at presentation. Conclusion: DKA is a life-threatening complication, and it became worse when it is related to COVID19. The incidence of DKA and mortality related to COVID19 increased when DKA occurs for T2DM subjects. A more prospective study is warranted and a longer duration of the study to establish the accurate incidence and mortality rate.
Outpatient Diabetic Outcome During the Covid-19 Pandemic: A Retrospective Single Center Analysis
Authors: Krahmer Robert , Thongprayoon Charat , Ruanpeng Darin 
Published: May 2021

Abstract
Background: Previous studies have shown that telemedicine is an effective alternative method for health care delivery. The COVID-19 pandemic has acutely stimulated expansion of telemedicine across the country. This study aimed to determine characteristics of telehealth visit and short term HbA1c outcome in patients with diabetes mellitus in endocrinology clinic during the COVID-19 pandemic. Methods: A single center retrospective chart review was conducted in all patients seen in endocrinology clinic for diabetes mellitus between 5/27/2020–7/20/2020. Data were extracted from electronic medical record. The primary research question is percentage of patients who achieved HbA1C ≤ 8% at 3 month follow up. Secondary research questions are characteristic of patients and clinic visits, diabetic technology usage, 3 month follow up mean HbA1c and HbA1c change. This project was approved by the institutional review boards. Results: Two hundred and six diabetic patients were seen: 72 (35%) in person, 49 (24%) phone visit, and 85 (41%) VDO visit. Mean age for patients adopted in person visit was 57 (SD 15) years, phone visit was 68 (SD 13) years and VDO visit was 54 (SD 18) years, p &lt;0.001. Male percentage for in person, phone and VDO visit was 44%, 59% and 61% respectively, p 0.09. New consult visit percentage for in person, phone and VDO visit was 7%, 2% and 5% respectively, p 0.46. Percentage of patients using insulin pump or continuous glucose monitoring for in person, phone and VDO visit was 33%, 43% and 54%, respectively, p 0.03. Baseline HbA1c was done in 89% (64/72) in person, 45% (22/49) phone and 52% (44/85) VDO visit. Among patients who had baseline HbA1c, average HbA1c was 8.6% (SD 1.8) for in person visit, 8.0% (SD 1.1) for phone visit and 8.1% (SD 1.8) for VDO visit, p 0.25. At 3 months, HbA1c was done in 38% of patients who had in person visit, 36% phone visit, and 43% VDO visit. Among patients who had 3 month follow up HbA1c, HbA1c ≤ 8% was achieved in 50%, 61% and 69% for in person, phone and VDO respectively, p 0.56. Mean 3 month follow up HbA1c was 8.1% (SD 1.3), 7.7% (SD 0.9) and 7.8% (SD 1.6) for in-person, phone and VDO visit respectively, p 0.47. Comparing mean HbA1c in patients who had both baseline and 3 month follow up HbA1c, changes were significant for in person visit 9.1% to 8.1% (p 0.01) and VDO visit 8.7% to 7.6% (p 0.01). No significant change in 3 month follow up HbA1c was observed in phone visit, 7.7% to 7.6% (p 0.88). Conclusions: This retrospective study showed that during the COVID-19 pandemic, no differences in short term HbA1c outcome (3 month follow up mean HbA1c and percentage of patients who achieved HbA1c ≤ 8%) were observed among patients who adopted in-person and telehealth visit. Patients who adopted phone visit appeared to be older; and there was more diabetic technology usage (insulin pump or continuous glucose monitoring) among patients who adopted telehealth (phone and VDO) compared to in person visit.
17q12 Deletion Syndrome. A Rare Association Between Diabetes and Renal/Urogenital Abnormalities
Authors: Perdomo Laura Sofia , Perdomo Rodriguez Juan Pablo 
Published: May 2021

Abstract
Introduction: Maturity onset diabetes of the young type 5 (MODY 5) is an autosomal dominant, non-autoimmune form of diabetes mellitus caused by HNF1b gene mutations/deletions. Because of a high prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in MODY 5 patients, understanding the extra-pancreatic manifestations of MODY 5 can target genetic testing to provide an earlier diagnosis.
Case Description: A 26-year-old male was referred for consultation after his primary care physician found an HbA1c of 11.4% and prescribed metformin 500mg/day. He reported weight loss during the previous weeks and a history of Attention Deficit Hyperactivity Disorder (ADHD). He denied urinary tract infections or renal disease. Family history included diabetes (24-year-old brother (also with ADHD) and both parents). His BMI was 17.07 kg/m2 and labs showed a normal lipid profile, including HDL-C 74 mg/dL; urine albumin 0.8 mg/dL; “inappropriately normal” insulin and c-peptide; and negative GAD65, IA-2, and ZNT8 antibodies. Glimepiride 1mg/day at breakfast was added, with referral to a geneticist to rule out MODY. A follow-up HbA1c was 7.1%; Januvia 100 mg/day was added. Glimepiride was later switched to glipizide 7.5 mg at breakfast and 2.5 mg at supper due to overnight hypoglycemia. Genetic testing revealed a male pathogenic 1.39 Mb deletion of 17q12 containing 20 genes, including HNF1b, consistent with MODY 5. Renal ultrasound showed mild hydronephrosis, increased echogenicity of both kidneys, and bilateral non-obstructing nephrolithiasis. Subsequently, his mother (previously diagnosed with diabetes, fatty liver disease, dyslipidemia, and multiple scattered non-obstructing calculi and cysts in both kidneys) was found to have the same genetic defect. His brother’s diabetes is currently well controlled with glargine 0.3 u/kg and aspart 0.05–0.15 u/kg/meal. Unlike the proband, he has obesity (BMI 30 kg/m2), dyslipidemia, and CKD (GFR 57 ml/min); further workup is pending at this time.
Discussion: Because patients with MODY 5 are at high risk for CKD3-4/ESRD, MODY 5 should be considered in young adults with diabetes who have negative islet autoantibodies and extra-pancreatic manifestations including elevated liver enzymes, renal cysts and nephrolithiasis; ADHD and learning difficulties; and pancreatic and hepatic morphological abnormalities. HNF1b-targeted genetic testing should be considered in patients with this clinical presentation.
A Bizarre Case of Recurrent Hypoglycemia
Authors: Pant Nicole , Steinberg Helmut O 
Published: May 2021

Abstract
Introduction: Severe hypoglycemia is extremely rare in non-diabetic subjects and requires thorough evaluation due to its life threatening consequences. Any injuries resulting from medication use, including physical harm, mental harm, or loss of function is defined as adverse drug events (ADEs). Medication errors can occur due to the inappropriate use of medicine in any prescription stage. We hereby present an intriguing case of recurrent hypoglycemia in relation to it. Case presentation: A 65 year-old white male with surgically induced panhypopituitarism on replacement hydrocortisone, levothyroxine and testosterone was transferred to our hospital with recurrent serious hypoglycemic episodes. He was in his usual state of health until about 2 weeks prior to presentation when he became increasingly fatigued. He was found to have severe hypoglycemia with a blood sugar of 20 mg/dl. He was treated for hypoglycemia and was discharged home 2 days later with an increased dose of hydrocortisone and the provisional diagnosis of adrenal crisis. At home, his symptoms of hypoglycemia recurred. He was then referred to our facility where the Endocrinology service was consulted. At admission, his blood sugar was 69 mg/dl, but it rapidly dropped down to 39 mg/dl with confirmatory serum glucose level of 24 mg/dl. He was started on Dextrose 10%. On further inquiry his daughter told us that she had discovered two different medications in one prescription bottle which had been refilled about 2 weeks prior to this hospitalization, coinciding with the onset of symptoms. The bottle in question was supposed to be for hydrocortisone 10 mg tablets, but it contained 2 different tablets with inscription GXL10 and P10. An online search identified tablets as Glucotrol-XL 10 mg and hydrocortisone 10 mg. Urine drug screen (UDS) for sulfonylureas and glinide was positive for Glipizide (203 ng/ml, normal level 0). His blood sugar stabilized with Dextrose and he was safely discharged home. So it was concluded that recurrent hypoglycemia was secondary to inadvertent administration of hypoglycemic agents, Glucotrol-XL 10 mg, likely aggravated by missing doses of hydrocortisone. Discussion: The first report of medication errors was published in 1940. ADEs comprise the largest single category of adverse events experienced by hospitalized patients,accounting for about 19 percent of all injuries. ADEs are associated with increased morbidity and mortality, prolonged hospitalizations, and higher costs of care. Four medications or medication classes were implicated in 67% of hospitalizations: warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents. ADEs in the outpatient setting are an important cause of emergency department visits and hospital admissions. This case emphasized the importance of taking a thorough history and focusing on patient safety and quality care in healthcare.
A Case of Euglycemic DKA With SGLT 2 Inhibitor Use- A Diagnostic and Therapeutic Dilemma
Authors: Nallu Ravali , Azmath Misbah , Aftab Hassaan , Kantorovich Vitaly 
Published: May 2021

Abstract
Background: The increasing use of SGLT-2 inhibitors driven by the apparent renal and cardiovascular benefits has been associated with increased incidence of euglycemic diabetic ketoacidosis (DKA), we present a case of euglycemic DKA following bariatric surgery in a patient on SGLT-2 inhibitors.
Case: 32 year old female with history of diabetes mellitus, obesity, hypertension, and triglyceride induced pancreatitis was admitted for an elective gastric sleeve procedure. She was diagnosed with type 2 diabetes after birth of her first child. Prior to the surgery she was treated with metformin 1000 mg twice daily, Empagliflozin 25 mg once daily, Tresiba 46 units and Humalog 12–15 units with each meal. She was placed on a strict calorie restricted diet leading up to the surgery. Empagliflozin and metformin were held 1 day prior to the surgery, insulin was decreased. Patient’s laparoscopic surgery was complicated by bleeding and hypotension and had to be converted to open surgery. Post operatively labs showed metabolic acidosis with bicarbonate level of 13 mmol/l (22–33), anion gap of 22 (7–17) and arterial pH of 7.29. Serum glucose of 223 mg/dl (65- 99), AST 541 u/l (10–50) ALT 580 u/l (10–50), beta hydroxy butyrate 5.89 mmol/l (&lt; 0.28), serum osmolality 305. Urinalysis showed a glucose of 500 mg /dl with the presence of large ketones. She was started on an insulin infusion and transferred to the ICU for close monitoring and management of euglycemic DKA. She was eventually transitioned to a basal bolus regimen of insulin at discharge with discontinuation of SGLT - 2 inhibitor therapy. Later, it was revealed that the patient had history of EDKA while on SGLT2 inhibitors, which was not reported to her new endocrinologist and hence she was re-initiated on them a year ago.
Discussion: Euglycemic DKA [EDKA] in the setting of SGLT- 2 inhibitor use has been associated with Type I diabetes with an incidence of 9.4 % whereas in type II at a rate of 0.2 %. In type 2 diabetics, it is more common in patients with beta cell insufficiency and may predict risk of developing type 1 diabetics which is likely the case in our patient. SGLT2 inhibitors act by promoting glucosuria, which in turn promotes sodium and ketone body reabsorption and increased ketone body production because of increased glucagon to insulin ratio. (1) Most patients with DKA while on SGLT 2 inhibitor have a precipitating event like dehydration, infection, surgery or change in insulin dose. We propose that strict carbohydrate diet and continuation of SGLT2 inhibitors before bariatric surgery resulted in EDKA. It led to complications peri-operatively. In conclusion, despite the increasing benefits of SGLT2 inhibitors in type 2 diabetics, one must be cognizant of its limitations and in particular association with EDKA. This especially holds true for patients suspected to have beta cell dysfunction or ketosis prone diabetes and patients on strict/low carbohydrate diets.
A Case of Immune Checkpoint Inhibitor Induced Autoimmune Diabetes
Authors: Thambuluru Sirisha Reddy 
Published: May 2021

Abstract
Introduction: Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that block checkpoints such as CTLA-4, PD-1, PDL-1 resulting in an antitumor immune response. ICIs can cause immune-related adverse events such as autoimmune diabetes. Clinical Case: 64 yr old male with history of non-small cell lung cancer (NSCLC) undergoing therapy with carboplatin, taxol, and pembrolizumab (monoclonal PD-1 receptor inhibitor) presented to the ED with weakness and dizziness. Patient reported a 1 week history of polyuria, fatigue, polydipsia, and weakness. He started his cancer treatment 2 months prior to presentation and received a total of 3 cycles with the last cycle being 3 weeks prior to presentation. Patient had no personal or family history of diabetes. On presentation to the ED vitals were: HR 130, RR 40, BP 166/100. Labs were significant for Na 122(135–145 mmol/L), bicarb 5(22–30 mmol/L), creatinine 1.76(0.70–1.30 mg/dl), glucose 1,147(70–179 mg/dl), beta hydroxybutyrate 10(0.02–0.27 mmol/L), anion gap 38(7–15 mmol/L), hemoglobin A1c 7.8%(4.8–5.6%), islet cell ab 0 (&lt;=0.02 nmol/L), GAD65 Ab 0.36 (&lt;=0.02 nmol/L). CT abdomen showed no pancreatic abnormalities. Patient was diagnosed with DKA from autoimmune diabetes induced by pembrolizumab. He was given fluids, started on an insulin drip and admitted to the ICU. He was transitioned off the insulin drip onto basal/basal insulin on discharge. One month post discharge the patient continues to require insulin. Learning points: Although the incidence of autoimmune diabetes mellitus associated with ICIs is only 0.2–0.9%, most of these patients present with severe DKA making this a dangerous adverse event that clinicians should be aware of1. The patient in this case had symptoms of new onset severe fatigue, polyuria, polydipsia 1 week prior to his presentation to the ED. This case teaches us that patients undergoing therapy with ICIs should be educated about the signs and symptoms of hyperglycemia and DKA, with directions to inform a health care provider should they occur. Potential interventions that will allow us to identify these patients prior to presentation with dangerous DKA include patient self-monitoring of symptoms and blood glucose checks with a glucometer. Reference: Akturk, H. K., Kahramangil, D., Sarwal, A., Hoffecker, L., Murad, M. H., & Michels, A. W. (2019). Immune checkpoint inhibitor-induced Type 1 diabetes: a systematic review and meta-analysis. Diabetic medicine: a journal of the British Diabetic Association, 36(9), 1075–1081. https://doi.org/10.1111/dme.14050
A Rare Cause of Diabetes: COVID-19
Authors: Rida Rima , Rios Paola , Manzano Alex 
Published: May 2021

Abstract
A Rare Cause of Diabetes: COVID-19
Introduction: Environmental factors like viruses have been described in the mechanism of pancreatic beta cell destruction. Various viruses can trigger autoimmunity in individuals genetically predisposed to diabetes. Severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) has been shown to bind to angiotensin-converting enzyme 2 (ACE 2) which is expressed throughout the body, including pancreatic cells, leading to direct injury of the endocrine pancreas. We report a case of coronavirus infection disease 2019 (COVID-19) causing a new onset of diabetes mellitus presentation with hyperglycemia, polyuria, polydipsia and weight loss.
Case Presentation: A 53 year-old, previously healthy, male presented with five days of fever, fatigue, dry cough, dyspnea and diarrhea. On admission he was hypoxic, with a body mass index of 25 kg/m2 and no evidence of insulin resistance on physical exam. He was diagnosed with SARS CoV-2 and admitted for high requirements of oxygen without the need of the intensive care unit. He was treated with tocilizumab, atazanavir, hydroxychloroquine, full dose anticoagulation and azithromycin. Dexamethasone 4 mg every 8 hours was given for three days. During this admission, his fasting glucose was 75–108 mg/dL. Once started on steroids his fasting and prandial glucose was 85–96 mg/dL and 140 mg/dL on one occasion. He was eventually discharged with 2 liters of nasal cannula which he required for one week. One and a half months after, he presented to the emergency department due to a 6 kg weight loss, polyuria, polydipsia, malaise and fatigue. On arrival his glucose was 549 mg/dL, without anion gap or ketones. He had no evidence of new infection and SARS CoV-2 test was negative. He was started on insulin glargine at night and insulin Humalog before each meal with corrections. Hemoglobin A1c was 13.4% with a C-peptide 0.36 ng/mL and glucose of 195 mg/dL at the time of C-peptide test. His antibodies, anti-islet cell antibody, zinc transporter 8 and glutamic acid decarboxylase-65, were negative. He was discharged with basal/bolus regimen and followed up outpatient with Endocrinology. During follow-up, his c-peptide normalized and he was tapered off insulin.
Discussion: In 2003, atypical pneumonia caused by SARS CoV-2 was reported to be associated with hyperglycemia in patients without prior history of diabetes. At 3 year follow-up, the patients no longer had diabetes. Moreover, patients with mild SARS CoV-2 during the first day of hospitalization had a higher fasting plasma glucose than patients admitted for other causes of pneumonia. It is known that SARS CoV-2 binds to ACE 2 which downregulates the receptor, leading to impairment of insulin secretion and hyperglycemia. SARS CoV-2 also produces a direct injury in beta pancreatic cells. It is imperative to monitor patients post COVID-19 to evaluate for new onset diabetes and likely resolution.
Approach to Diagnosis and Management Latent Autoimmune Diabetes in Adults: A Case Report
Authors: Gemiana Dita , Alfian Andi , Tahapary Dicky Levenus , Rachman Andhika 
Published: May 2021

Abstract
Introduction:. Latent Autoimmune Diabetes in Adults (LADA) is used to describe a form of autoimmune diabetesthat has a later onset and a slower progression toward an absolute insulin requirement. The presence of pancreaticauto antibodies especially to Glutamic acid decarboxylase (GAD65) is the best single marker required to diagnoseLADA. Case Illustration. A 35-year-old male came to emergency room with complaints of shortness of breath since twodays before admission. Tightness was not affected by activities or changes in position. The patient also hadcomplaints of vomiting since 3 days before admission. There was a weight loss of 10 kg in the last 1 month andcomplaint urinated frequently. There is no family history of diabetes and autoimmunity. The patient’s blood sugarlevel was 422 mg/dL, blood ketone was 5.6 mmol/L, and the blood gas analysis showed metabolic acidosis. The c-peptide level was 0.35 ng/mL (1.1 - 4.4 ng/mL). Patients was positive for glutamic acid decarboxylase (GAD)autoantibodies. Patients was diagnose with LADA and treated with basal insulin 1x36 unit and prandial insulin 3x20unit. Discussion: C-peptide is mostly undetectable in classical T1DM and normal or high in patients with newlydiagnosed T2DM, whereas individuals with LADA tend to have low but still detectable C-peptide values at the timeof diagnosis. Thus, islet autoantibodies screening, especially GADA, should be required as a second step for patientswith adult-onset diabetes showing low serum C-peptide. To date, evidence shows that patients with LADA shouldbe treated with insulin at an earlier stage. Conclusion: Routine GADA screening should be considered. However, since testing for islet-cell autoantibodiesmay not always be indicated because of high costs, C-peptide measurement may be a useful tool to rule outdiagnosis of LADA in case of low clinical suspicion.