bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prolonged Hypoglycemic Effect Due to Intentional Massive Insulin Glargine Overdose
Authors: Gill Kirit S , Arao Kevin A , Merolli Alisa 
Published: May 2021

Abstract
Introduction: Since its discovery in 1921, insulin has served as the mainstay of treatment for patients with both type 1 and insulin-dependent type 2 diabetes mellitus (T2DM). Insulin is available in both long and short acting formulations. Glargine, a long-acting insulin, has an onset of action in one to two hours and length of duration of 24 hours. Although generally well tolerated, when taken in overdose, insulin can lead to severe hypoglycemia, seizures, unconsciousness, or even death. We present a case of an insulin-dependent male with refractory hypoglycemia after an intentional glargine overdose.
Case: A 57-year-old man with past medical history of insulin-dependent T2DM, alcohol abuse, cirrhosis, and depression, presented to the hospital after a suicide attempt. The patient reported that after a night of drinking he experienced suicidal thoughts and injected himself with 8 vials of 100 Units (800 units) of insulin glargine. On initial presentation, the patient had a GCS of 15/15 and was in slight distress. The remainder of his exam was normal. Initial laboratory workup was pertinent for a blood glucose of 86mg/dL. Poison control was contacted and the patient was started on an intravenous infusion of 10% Dextrose with blood glucose checks every 15 minutes; subsequently reduced to every 60 minutes. Despite continuous glucose administration, the patient still suffered from severe hypoglycemic episodes (glucose &lt; 70mg/dL) requiring glucose boluses in the first 96 hours of hospitalization. His glucose infusion was transitioned to D5 and then discontinued. Psychiatry determined the patient was no longer a risk to himself and outpatient therapy was warranted. His blood glucose was well controlled and he was not discharged with insulin.
Discussion: Insulin glargine is a long-acting human insulin analogue with a prolonged activity profile and no pronounced peak. At doses between 0.4 IU/kg to 0.8 IU/kg, insulin glargine is metabolized in 24 hours. However, in cases of insulin overdose, insulin effects and absorption are highly variable. Multiple studies have illustrated the unusual prolonged hypoglycemic effect of glargine after massive doses. The mechanism behind this is still unclear but several factors may result in this prolonged duration of action. Larger injection volumes create a larger depot that may have a mechanical effect on the microcirculation leading to delayed absorption. Presence of lipodystrophy from repeated insulin injection, hepatic impairment, and renal impairment may also alter insulin kinetics. Another contributing factor in our patient is obesity, which is associated with delayed insulin absorption.
Conclusion: Insulin glargine overdose can lead to prolonged hypoglycemic effect due to altered pharmacokinetics. Physicians should be cognizant about this and closely monitor blood glucose levels and anticipate the possibility for prolonged IV dextrose infusion.
Severe Hypoglycemia in a Non-Diabetic Patient
Authors: Thomas Melbin , Krug Esther 
Published: May 2021

Abstract
Introduction: Accidental ingestion of insulin secretagogue may result in severe life-threatening hypoglycemia. Patients in long-term care may be especially vulnerable if proper medication administration safety guidelines are not followed. Case: A 62-year-old woman who was staying at a residential living facility (RLF) for the homeless, presented to the emergency room with altered mental status. Her past medical history included hypertension, COPD, psoriasis, and alcohol abuse. Prior to arriving to the emergency room, she was drinking alcohol excessively. Head CT results were normal. Capillary blood glucose (FBG) level was noted to 38 on EMS arrival. Her FBG improved to 69 after glucagon and her mental status improved shortly afterwards. ED was planning on discharging her when she became unresponsive with tonic-clonic seizure-like activity. The FBG at that time was 17. She was given Ativan and 10% Dextrose IV followed by 5% Dextrose Normal Saline (D5NS) drip. She recovered consciousness and was admitted for further monitoring. Endocrinology was consulted for hypoglycemia (HG). The patient denied prior diagnosis of diabetes mellitus or access to diabetic medications. Her medications were dispensed to her daily by staff at RLF. We held D5NS in order to perform testing for HG. Within 30 minutes she developed symptoms of HG. Hypoglycemic profile labs including C-peptide, insulin, beta-hydroxybutyrate, pro-insulin, hypoglycemic agent screen, insulin antibodies were drawn prior to reversal of HG. Laboratory findings: Venous BG - 26 mg/dL. Beta-hydroxybutyrate level (BHB) - 0.02 mmol/L (n, 0.02–0.27). The insulin antibody - 6.9 ng/mL (n, &lt;5). C-peptide - 8.5 uU/mL (n, 1.1–4.4), insulin level - 53.2 uIU/mL (n, 2.6–24.9). Proinsulin - 8.6 pmol/L (n, &lt;10.0). She had normal GFR of 95.94 mL/min/1.73m2 (n, &gt;60) and elevated liver enzymes. Abdominal ultrasound results were consisted with cirrhosis. HG resolved after 36 hours. HG drug screen performed at Mayo Clinic lab by highly sensitive LC/MS/MS assay was positive for Glimepiride. Discussion: This case illustrates importance of high degree of suspicion for drug-induced HG in a patient presenting with profound HG and no previous history of diabetes. Discharging this patient prematurely could have resulted in hypoglycemic coma and death. Severity of HG was not consistent with alcoholism and cirrhosis. Suppressed BHB level coupled with high-normal pro-insulin and markedly elevated C-peptide and insulin levels were consistent with endogenous hyperinsulinemia. Sulfonylureas are known to have a long half-life; hypoglycemic effect can last for 12 to 24 hours or longer, especially in patients with impaired kidney or hepatic dysfunction. Since results of HG work-up are typically not available for several days, clinical observation and avoidance of premature discharge following initial reversal of HG are very important.
Two Extremes of Dysglycemia- a Rare Case of Diabetes Complicated With a Non-Functional Pancreatic Neuroendocrine Tumor Transforming to an Insulinoma
Authors: Schleis Gregory , Rasouli Neda 
Published: May 2021

Abstract
Background: Diabetes is characterized by hyperglycemia with heterogeneous pathophysiological features and varied presentation and consequences. Here, we present a rare case of diabetes that was complicated with insulinoma making glycemia management complicated.
Clinical Case: A 48-year-old white man was diagnosed with diabetes when he presented with weight loss, polyuria and polydipsia and HbA1c of 11%. He was treated with oral agents for few months without a good response then switched to insulin. He was assumed to have type 1 diabetes and had fairly well controlled glycemia on multi daily injection of insulin. He was diagnosed with a metastatic non-functional pancreatic neuroendocrine tumor (PTEN) 9 years later. He presented with epigastric pain and CT scan showed a mass in the pancreas tail and multiple lesions in liver. The tumor was immunopositive for S100, synaptophysin, and chromogranin. He was first treated with sunitinib and later switched to Everolimus. He underwent treatment with SIR-spheres which was complicated with post-embolization syndrome and Diabetes Ketoacidosis (DKA). He was switched back to Everolimus and referred to the endocrinology clinic for management of diabetes with a recent DKA. At the initial evaluation by the endocrinology team, he had BMI of 25 kg/m2, no significant family history of diabetes, no diagnosis of dyslipidemia or hypertension. He had low C-peptide &lt; 0.1 ng/mL (n: 0.8 - 5.2 ng/mL) and negative GAD antibody suggestive of non-immune mediated insulin deficient diabetes. He was treated with basal plus prandial insulin regimen and required about 0.6–0.7 unit/kg of insulin each day. Due to progression of PTEN, he was started on monthly Lanreotide while later Pembrolizumab was added resulting in hypothyroidism with a TSH of 75 mIU/L (n: 0.45 - 5.33 mIU/L) that was treated with Levothyroxine. Meanwhile, his diabetes care was complicated by recurrent hypoglycemic episodes and hypoglycemia unawareness. He gradually decreased the dose of insulin, stopped taking prandial insulin, and finally discontinued basal insulin due to recurrent hypoglycemia. He continued to have hypoglycemia despite stopping insulin. His C-peptide was found to be 3.3 ng/mL with a low BG of 62 mg/dl. Diazoxide was started and despite maximizing the dose, the patient continued experiencing hypoglycemia. He therefore decided to stop taking Diazoxide and only continued monthly Lanreotide. The patient is currently avoiding hypoglycemia by eating frequently (every 3 hours) and has regained his hypoglycemia awareness.
Conclusion: This is a rare case of non-immune mediated insulin deficient diabetes complicated by recurrent episodes of hypoglycemia due to a non-functioning PNET converting to a functional tumor producing insulin.
Fetuin-A as a Marker of NAFLD
Authors: Dharmalingam Mala , Pattabhi Ganavi 
Published: May 2021

Abstract
Fetuin-A has been implicated in the causation of metabolic disorders such as obesity, diabetes, and hepatic steatosis. There are numerous studies which have shown the association between levels of fetuin-A in Type 2 diabetes mellitus (T2DM) and Nonalcoholic fatty liver disease (NAFLD). The levels of fetuin-A in newly detected type 2 diabetic patients (NDD) and its correlation with presence of NAFLD has not been studied. Objective: To study the fetuin-A levels in patients with NDD and its correlation with NAFLD. Methods: A total of 60 newly diagnosed type 2 diabetes (NDD) were studied. Diagnosis of NAFLD was made on the basis of transient elastography. Serum fetuin-A and serum fasting insulin were measured along with other investigations. Results: Percentage of patients with NAFLD in NDD was 53.33%. Fetuin-A levels were significantly higher in NDD with NAFLD compared to those without NAFLD. There was no association of fetuin-A with age, both systolic and diastolic blood pressure, FBS, HbA1c, fasting insulin, HOMA-IR, QUICKI and markers of advanced fibrosis. Fetuin-A levels beyond 1166.5 mcg/ml could predict the development of NAFLD with OR of 4.33 (95%CI:1.364–13.77) which remained significant after adjustment for various confounding factors. Conclusion: Fetuin-A is a reliable marker of NAFLD in NDD and is positively associated with IR. The observation in this study suggests that high serum fetuin-A levels in patients with NAFLD do not merely reflect the effects of insulin resistance, but also a more extensive distortion of liver architecture.
Glycemic Control & Morbidity in Diabetics With COPD Exacerbation. A Retrospective Study
Authors: Naoum Ibrahim , Abedalhalim Abedalghani , Aker Amir , Khalaili Luai , Kassem Sameer 
Published: May 2021

Abstract
Background: Diabetes and chronic obstructive pulmonary disease (COPD) are widely prevalent and comorbidity with these diseases is quite common. However, there is limited data on the interrelation between glycemic control and COPD exacerbations in diabetic patients.
Objective: To study the association between pre-admission glycemic control and COPD clinical outcomes including mortality, risk of hospital readmission and the need for mechanical ventilation.
Methods: A retrospective population-based cohort study. We screened for patients with both diabetes and COPD exacerbation aged 35 years and above. Pre-admission glycemic control was defined by the last HBA1C level prior to hospitalization. Patients with HBA1C&gt;8% were defined as uncontrolled. We evaluated the difference between controlled and uncontrolled groups in the rates of mortality, readmission and the need for mechanical ventilation. We examined demographic and clinical parameters that might reflect COPD severity including: COPD medication use, blood hemoglobin, platelets, LDH and CRP levels.
Results: 513 hospitalizations with diabetes and COPD were screened. 222 hospitalization were excluded either due to unestablished diagnosis of COPD or due to lack of HBA1C test in the preceding year. Of the remaining 291, 208 admissions were with controlled diabetes whereas 83 were uncontrolled. Although not statistically significant, the rate of re-hospitalization was higher in the uncontrolled group (OR 1.99, CI 0.99–4.0, p-value 0.051). There was no statistically significant difference in mortality (OR 1.6, CI 0.73–3.5, p-value 0.243). The use of oxygen and the need for noninvasive mechanical ventilation were significantly higher in the uncontrolled group (67.5% vs. 52.4%, p-value 0.019, 33.7% versus 18.8%, p-value 0.006, respectively). There was no significant difference in possible confounders tested between the groups.
Conclusion: Uncontrolled diabetes may adversely affect patients with COPD exacerbation. Larger studies are needed to conclusively determine the impact of glycemic control on COPD morbidity and mortality.
Immune Checkpoint Inhibitor Mediated Insulin Dependent Diabetes: Observations at a Cancer Center
Authors: Jeun Rebecca , Best Conor , Iyer Priyanka , Lavis Victor Ralph , Varghese Jeena Mary , Oliva Isabella Glitza , Dadu Ramona , Thosani Sonali 
Published: May 2021

Abstract
Immune checkpoint inhibitors (ICIs) have rapidly changed the landscape of oncologic care and are now often used in the front line setting for many types of cancers. These agents attempt to harness the immune system to target cancer cells (ICIs) by releasing inhibition of T cell response against tumor cells. With increasing use of ICIs, a new spectrum of immune-related adverse events (irAEs) has emerged including a number of endocrinopathies. A distinct form of ICI-mediated insulin dependent diabetes (ICI-DM) has become increasingly recognized. To better characterize this disease entity and longer-term consequences, we performed a retrospective review of medical records of patients diagnosed with ICI-DM between April 2014 and July 2020 at the MD Anderson Cancer Center. This cohort of 68 patients represent the largest single institution cohort described to date. Baseline characteristics of our cohort are consistent with what has been reported in other case series and meta-analyses with median age at presentation 61 years old (range 32–83 years old), slight male predominance (59% vs 41%), and strong association with anti-programmed cell death protein 1 (anti-PD-1) therapy (59%). Melanoma was the most commonly represented underlying malignancy (29%). The majority of patients (66%) presented with diabetic ketoacidosis. At presentation, median HbA1c was 7.8 % (n &lt; 5.7%) and median C-peptide was 0.2 ng/ml (range &lt;0.1–3.4). Pancreatic autoantibodies were present in 49% of patients. Median insulin dose was 0.54 units per kg per day[T1] (range 0.25 to 1.07 units per kg) at first follow up suggesting these patients may have varying levels of insulin sensitivity[T2]. On most recent follow up at a median[T3] of 40 weeks (range 8 to 261 weeks), median HbA1c was 7.9% and median insulin requirement remained 0.54 units per kg (range 0.14 to 1.2 units per kg). 22% of patients were on insulin pump therapy[T4]. ICI-DM is an irreversible immune-related adverse endocrinopathy characterized by frequent presentation with fulminant hyperglycemia and DKA, persistent beta cell dysfunction necessitating long term insulin therapy and mixed evidence of beta-cell autoimmunity. Median insulin requirement was more consistent with type 1 diabetes, but a wide range was present. Adequate glycemic control was generally achievable on insulin therapy.
Screening for Asymptomatic Coronary Artery Disease in People With Type2 Diabetes Mellitus in a Tertiary Care Center
Authors: Tewari Ajoy 
Published: May 2021

Abstract
Cardiovascular disease is the biggest driver of mortality in people with diabetes. Cardiovascular disease and diabetes share the same risk factors, the so-called “common soil” hypothesis. Asians and more specifically Indians are predisposed to cardiovascular disease, that too at an earlier age. The cost of management of cardiovascular disease in India is prohibitive. Thus, screening for asymptomatic coronary artery disease in people with type 2 diabetes and referring them for further evaluation will go a long way in preventing cardiovascular mortality. 560 consenting previously diagnosed people with type 2 diabetes, undergoing treatment for type 2 diabetes at our center, were recruited in the study. We used the risk score model for the assessment of coronary artery disease in asymptomatic patients with type 2 diabetes (1) because it was easy to use, specific for Asian population and validated with coronary computed tomographic angiography in asymptomatic people with type 2 diabetes. Questions regarding smoking, past history of stroke and duration of diabetes were recorded as per the risk score and accordingly the subjects were labelled low, intermediate and high risk. Anthropometric measurements were recorded, lipid profile was measured, neuropathy assessment was done using the DNS score. Results: 48.9%subjects were females,51.1% were males, mean duration of diabetes was 3.5 years, mean HbA1c was 8.5%, mean BMI 26.5kg/m2, mean age was 51.4 years, mean CAD score was 4.1 44.2% of the subjects were in a low risk category, 44.9% were in the intermediate risk category and 10.9% in the high-risk category. The maximum people had intermediate to high risk and were in the age group of 50–60 years (21.3%), followed by 13% in the 60–70 age group. Surprisingly, 12.6% people in the 40-50year age group had an intermediate to high risk score for ASCVD. The high prevalence of intermediate to high risk in relatively younger populations with shorter duration of diabetes (mean duration of diabetes 3.5 years) mandates universal screening for asymptomatic coronary artery disease in all people with type 2 diabetes mellitus. Our study highlights the importance of identifying asymptomatic coronary artery disease using locally relevant risk models and their timely referral to prevent excessive cardiovascular mortality in people with type 2 diabetes mellitus. This would ensure optimum utilization and prioritization of scarce resources in resource crunch situations. Keywords: Screening, asymptomatic CAD, type 2 diabetes mellitus. References: 1. Park G-M, An H, Lee S-W, Cho Y-R, Gil EH, Her SH, et al. Risk Score Model for the Assessment of Coronary Artery Disease in Asymptomatic Patients With Type 2 Diabetes. Medicine [Internet]. 2015 Jan [cited 2020 Oct 14];94(4):e508. Available from: https://journals.lww.com/md-journal/Fulltext/2015/01040/Risk_Score_Model_for_the_Assessment_of_Coronary.44.aspx
The Possible Link Between Serum Lipocalin-2 Level and Mild Cognitive Impairment in Adults With Metabolic Syndrome
Authors: Pinyopornpanish Kanokporn , Phrommintikul Arintaya , Angkurawaranon Chaisiri , Kumfu Sirinart , Chattipakorn Nipon , Chattipakorn Siriporn C 
Published: May 2021

Abstract
Introduction: Metabolic syndrome (MetS) is associated with an increased risk of cognitive impairment. Lipocalin-2 (LCN2) or neutrophil gelatinase-associated lipocalin (NGAL), is an inflammatory protein, and participates in the innate immune response. LCN2 significantly decreased in the cerebrospinal fluid of individuals with mild cognitive impairment. A recent study reported that circulating lipocalin-2 is involved in early AD pathogenesis. However, the association of LCN2 and cognition in MetS patients are still unclear. Then, the present study aims to evaluate whether serum LCN2 levels are associated with the alteration of cognitive function in MetS subjects.
Methods: Participants with MetS, but without dementia or prior psychiatric problems, were enrolled to the study. The demographic data and physical examination were assembled. Blood samples were collected to evaluate the metabolic parameters. Levels of serum LCN2 were determined with ELISA assay. The global score of the Thai version of Montreal cognitive assessment (MoCA) was used to assess cognitive function. Multivariable regression analysis was used to determine the associations.
Results: Among 202 MetS participants, 111 (54.95 %) were female, and average age was 64.6 (SD 8.6). Mean serum LCN2 and MoCA score were 30.7 ng/ml (SD 17.6) and 19.3 (SD 4.8), respectively. Serum LCN2 levels were negatively associated with the MoCA scores in crude analysis (B=-0.053; 95%CI -0.090, -0.015; p 0.006). After adjustment for sex, age, waist circumference, and creatinine levels, there was an association between the higher serum LCN2 levels and the lower MoCA scores (B=-0.049; 95%CI -0.090, -0.008; p 0.019).
Conclusion: These findings suggest the association between serum LCN2 levels and MCI in MetS subjects. However, further longitudinal study should be investigated to support the link between serum LCN2 levels and cognitive impairment.
Integration of Flash Glucose Monitoring During the Transition of Care From Inpatient to Outpatient Settings in Patients With Type 2 Diabetes
Authors: Jaiswal Radhika , Zhang Meng , Zuniga Sharon , Myers Alyson K 
Published: May 2021

Abstract
Background: The use of continuous glucose monitoring (CGM) technology in the outpatient setting has been associated with both improved patient satisfaction1 and increased glucose monitoring2. It remains to be seen, how well this technology can be integrated during the transition from hospital discharge to outpatient settings. Here, we aim to assess the feasibility of introducing the FreeStyle Libre during the transition of care from inpatient to the outpatient environment in patients with Type 2 diabetes (T2D). We will assess CGM use as measured by the numbers of days used and frequency of daily scans. Methods: During the time period April and September 2020, 20 patients with T2D being discharged on multiple daily injections admitted to North Shore University Hospital were enrolled in this study. Exclusion criteria were those with adhesive allergy, CKD 4/5 or on dialysis and pregnant women. Participants were trained on how to use the FreeStyle Libre with the LibreLink mobile application. All patients received 2 Libre sensors at the time of discharge, one that was placed in the hospital and the other to be placed after 14 days. 1 participant died prior to discharge. Analyses included descriptive statistics, specifically categorical variables using frequencies and percentages while continuous variables using mean and standard deviation. Results: Among who used the mobile application, 10 were men and 9 were women. Majority of patients were Black (n=11, 57.9%) with a mean age of 52 years (range 31–76). The mean duration of diabetes was 9.7 years (range: 0 to 22) and mean Hemoglobin A1c of 11.2% (range: 5.5–15.5). 10 out of 19 persons used CGM for more than 2 weeks, while the remaining 9 utilized the CGM for less than 2 weeks. Mean average daily scans were 5 times per day (range: 1–12) with majority of the persons (n=15, 78.9%) scanning more frequently (3 or more times per day). The average glucose ranged from 62 to 268 mg/dl and the mean active CGM time was 52.05% (range 0–98). Mean glycemic variability was 29.17% (range: 14.5–56.7). Technical issues with the CGM included poor adhesion or issues connecting to the mobile application.
Conclusion: Our study found that the initiation of CGM during the transition from hospital discharge to the outpatient setting is feasible and a useful tool. A limitation of this study was the inability for all people to use the mobile application due to incompatible phones or operating systems. References: 1. Beck RW, Riddlesworth TD, Ruedy K, et al. Continuous Glucose Monitoring Versus Usual Care in Patients With Type 2 Diabetes Receiving Multiple Daily Insulin Injections. Ann Intern Med. 2017;167(6):365–374. doi:10.7326/M16-2855. 2. Shehav-Zaltzman G, Segal G, Konvalina N, Tirosh A. Remote Glucose Monitoring of Hospitalized, Quarantined Patients With Diabetes and COVID-19. Diabetes Care. 2020;43(7):e75-e76. doi:10.2337/dc20-0696.