bluuebunny/crossref_metadata_2025_split huggingface dataset:
THU310 A Presentation Of Diabetic Ketoacidosis In Gestational Diabetes
Authors: Yim Carly , Laura Liu Selina , Spaic Tamara 
Published: October 2023

Abstract
Disclosure: C. Yim: None. S.L. Liu: None. T. Spaic: None.
Diabetic ketoacidosis (DKA) is a diabetic emergency characterized by wide anion gap acidosis, presence of ketones (in serum and/or urine) and, frequently, uncontrolled hyperglycemia. In pregnancy, DKA more commonly occurs in women with pre-existing diabetes, usually type 1 diabetes, and is exceptionally rare in women with gestational diabetes mellitus (GDM). We report a case of a 37-year-old woman in her second pregnancy who presented to hospital with DKA at 29+3 weeks gestation shortly after diagnosis of GDM 4 days earlier.
In her first pregnancy, she was diagnosed with GDM at 28 weeks, required treatment with metformin at 35 weeks, which she stopped postpartum. She conceived her second pregnancy 3 months postpartum so was not screened for diabetes postpartum. In her second pregnancy, there was no evidence of diabetes on early antenatal labwork at 7 weeks: Hemoglobin A1c (HbA1c) 5.6%, random glucose 3.6 mmol/L. Early GDM screening at 21+1 weeks with 75 gram oral glucose tolerance test (OGTT) was normal: fasting glucose 4.4 mmol/L 1-hour glucose 9.0 mmol/L, 2-hour glucose 6.5 mmol/L.
She presented to hospital at 29+3 weeks gestation with a 2-day history of polyuria, polydipsia, dizziness, and decreased oral intake without nausea or vomiting. Four days prior to presentation, she was diagnosed with GDM on a 75g OGTT (fasting glucose 6.2 mmol/L, 1-hour glucose 15.1 mmol/L, 2-hour glucose 11.9mmol/L). Admission labwork showed serum glucose 34.8 mmol/L, anion gap 18, pH 7.29, bicarbonate 17 and beta-hydroxybutyrate 2.97. She was treated with IV fluids and insulin and initiated on multiple daily injections of insulin. Other than pregnancy, no clear precipitating factor was found. HbA1C was 6.4%, serum insulin and C-peptide levels were inappropriately low at 22 pmol/L and 296 pmol/L respectively. Her anti-glutamic acid decarboxylase and anti-islet cell antibodies were negative. Lipase was mildly elevated at 226U/L but improved to 144U/L with treatment. Abdominal ultrasound did not demonstrate any findings suggestive of acute pancreatitis. Her 24-hour urinary free cortisol was 366 nmol and 442 nmol, both within normal trimester-specific range. Her salivary cortisol was in the normal range (10.5nmol and 10.9nmol). Following discharge, she remained significantly insulin resistant with suboptimal glycemic control (total daily insulin requirements ∼3.5 units/kg/day, HbA1C 7.9% at 35+6 weeks).
Due to increased insulin resistance in pregnancy, DKA can progress more rapidly compared to nonpregnancy. Given increased rates of perinatal morbidity and mortality associated with DKA, treatment and monitoring should be promptly initiated. A high index of suspicion is especially important given that DKA is a rare presentation in GDM. Other precipitating factors of newly decompensated diabetes should also be ruled out.
Presentation: Thursday, June 15, 2023
THU328 Appropriate Initial Insulin Dosage For Management Of Steroid-induced Hyperglycemia In Hospitalized COVID-19 Patients
Authors: Ketaroonrut Nuttavadee , Kiertiburanakul Sasisopin , Sriphrapradang Chutintorn 
Published: October 2023

Abstract
Disclosure: N. Ketaroonrut: None. S. Kiertiburanakul: None. C. Sriphrapradang: None.
Introduction: Steroid was recommended for the treatment of severe COVID-19 infection. There are limited studies on the management of steroid-associated hyperglycemia in hospitalized COVID-19 patients. We aimed to determine the appropriate initial insulin dosage to control hyperglycemia in hospitalized COVID-19 patients who received steroid therapy. Methods: We conducted a retrospective single-center analysis of electronic medical records of COVID-19 patients with steroid-induced hyperglycemia who had been treated with insulin. We divided the patients into 4 groups according to the total daily dose (TDD) of subcutaneous insulin therapy at the initiation of dexamethasone ≥6 mg/day or an equivalent dose of glucocorticoid. Glycemic outcomes were compared between groups. Results: A total of 156 patients [age 64±14 years; 50% men; body mass index 26.9±6.9 kg/m2; initial TDD of insulin (units/kg/day): group A, &lt;0.29 (n=79); group B, 0.3-0.49 (n=33); group C, 0.5-0.69 (n=27); group D, &gt;0.7 (n=17)] were included. Most patients (62%) had pre-existing type 2 diabetes. Mean admission blood glucose (BG) and HbA1c were 233±112 mg/dL and 7.8±2.3%, respectively. HbA1c was lowest in group A (6.7±1.2%) and highest in group D (9.8±2.5%). The average daily dexamethasone dosage or equivalent was 49.49±45.4 mg and there were no significant differences between the groups in the dexamethasone dose. The proportion of treatment failure (mean BG &gt;280 mg/dL after the first day of insulin therapy or BG &gt;400 mg/dL for at least 1 time/day) was lowest in group A. Among patients who received TDD &gt;0.3 units/kg/day, group D had the lowest in both the percentage of treatment failure (B (52%) vs C (37%) vs D (29.4%), p=0.006) and mean BG during the 3 days of insulin therapy (B (246.0± 56.7 mg/dL) vs C (246.9±59.0 mg/dL) vs D (228.5±64.4 mg/dL), p=0.21). Three patients had severe hypoglycemia (BG &lt;54 mg/dL) in this study (A: n=1 vs B: n=1 vs C: n=0 vs D: n=1, p=0.51). Conclusions: In the patients who require TDD &gt;0.3 units/kg/day, the treatment failure of hyperglycemia was lowest in the patients who received TDD &gt;0.7 units/kg/day without increasing severe hypoglycemia. This initial insulin dosage may guide physicians to achieve better glycemic control among hospitalized COVID-19 patients who received steroid therapy.
Presentation: Thursday, June 15, 2023
THU340 Efficacy And Safety Of Low-dose Spironolactone On Chronic Kidney Disease In Adults With Type 2 Diabetes: A Multicenter, Randomized Clinical Trial
Authors: Oiwa Ako , Hiwatashi Dai , Takeda Teiji , Miyamoto Takahide , Kawata Iori , Koinuma Masayoshi , Kubota Satoshi , Takayama Shyouhei , Yamazaki Masanori , Komatsu Mitsuhisa 
Published: October 2023

Abstract
Disclosure: A. Oiwa: None. D. Hiwatashi: None. T. Takeda: None. T. Miyamoto: None. I. Kawata: None. M. Koinuma: None. S. Kubota: None. S. Takayama: None. M. Yamazaki: None. M. Komatsu: None.
Objective: To evaluate the albuminuria-lowering effect and safety regarding hyperkalemia of adding low-dose spironolactone (12.5 mg/day) to the renin-angiotensin system (RAS) blockers in adults with chronic kidney disease and type 2 diabetes. Research Design and Methods: This was a multicenter, open-label, randomized controlled trial. We enrolled 130 Japanese individuals aged ≥20 years with type 2 diabetes and albuminuria (≥30 mg/gCre), estimated glomerular filtration ≥30 mL/min/1.73 m2, and serum potassium level &lt;5.0 mEq/L. They were randomly assigned to the spironolactone-administered and control groups. The main outcomes were changes in urine albumin-to-creatinine ratio (UACR), serum potassium levels and renal function from baseline to the 24-week interventional period. Results: The spironolactone-administered group showed a significant reduction in UACR by a mean of 103.47 ± 340.80 mg/gCre from baseline compared with the control group that showed increased UACR by a mean of 63.93 ± 310.14 mg/gCre (p = 0.0007, Wilcoxon rank-sum test and T-test). As for serum potassium levels, although there was a statistically significant increase (p = 0.0026), none of the participants had a potassium level ≥5.5 mEq/L at 24 weeks. Further, there was a tendency that the higher the initial potassium level, the smaller the increase in serum potassium level (estimate −0.37, analysis of covariance). Conclusions: This study first demonstrated that low-dose spironolactone administration reliably reduced albuminuria and was safe against hyperkalemia. The administration of spironolactone, which is the oldest known and most cost-effective of all the other mineralocorticoid receptor antagonists, should be re-evaluated with consideration of lower doses.
Presentation: Thursday, June 15, 2023
THU344 Pandemic Effect On National Hospitalizations For Acute Hyperglycemic Complications In Adults With Diabetes
Authors: Krishnaraju Ellil , Israel Ilelaboye Ayodeji , Kanemo Philip , Vardar Ufuk , Bess Olva , Baskaran Naveen , Shaka Hafeez 
Published: October 2023

Abstract
Disclosure: E. Krishnaraju: None. A.I. Ilelaboye: None. P. Kanemo: None. U. Vardar: None. O. Bess: None. N. Baskaran: None. H. Shaka: None.
Introduction: In 2020, The SARS-CoV-2 outbreak (COVID-19) was quickly classified as a pandemic, prompting a nationwide lockdown. Numerous studies have implicated patients with diabetes to have a higher susceptibility to the COVID-19 virus and more deleterious hospital outcomes. This study aims to describe the effect of the COVID-19 pandemic on epidemiologic trends, and disparities in outcomes among hospitalizations with acute hyperglycemic complications (AHC). Methods: This was a retrospective study of the National Inpatient Sample (NIS) database from 2016 to 2020. The NIS was searched for hospitalization of adults with AHCs. We defined AHC as hospitalizations with diabetic ketoacidosis (DKA) in T1D and DKA and hyperglycemic hyperosmolar state (HHS) in T2D. The admission rate for each calendar year was obtained as admissions per 100,000 adults hospitalized. We obtained the AHC admission rates per 100,000 adult hospitalizations during each calendar year in adults with T1D and T2D. We then compared the admission rate and in-hospital mortality rate in 2019 and 2020 to estimate the pandemic effect. This study also highlights disparities in outcomes of hospitalizations for AHC stratified by sex, race, income quartile, and hospital regions. Results: Pre-pandemic, there was a gradual increase in the number of hospitalizations for AHC in T1D. During the pandemic, there was a decrease in the AHC hospitalization rate per 100,000 admissions for T1D (577 vs 600). However, there was an increase in T2D (117 vs 125). There was no statistically significant difference observed in mortality in T1D (0.20 vs 0.23 p=0.419) and T2D (1.1 vs 0.8 p=0.098). There was also no difference in mortality after stratifying into gender, race, median household income, and hospital region. During the pandemic, COVID-19 was the principal diagnosis in 5.5% of those with AHC in T1D and 9.1% in those with AHC in T2D. However, COVID-19 was a comorbidity in about one in five and one in six mortalities associated with AHC in T1D and T2D respectively. Conclusion: We found that the pandemic had a reciprocal impact on the hospitalization rate for AHC in both T1D and T2D. This brings to light the sheer impact that the COVID pandemic has had and the complex variables that may affect glycemic control. It will be helpful to further stratify the variables that influence AHC hospitalizations to tailor treatment, improve glycemic control and minimize hospitalizations in the future.
Presentation: Thursday, June 15, 2023
THU349 Association Of Non-alcoholic Fatty Liver Disease And Type 2 Diabetes Mellitus - A Cross-Sectional Study
Authors: Amaan Parvez Mohammad , Patel Urvish K 
Published: October 2023

Abstract
Disclosure: M. Parvez: None. U.K. Patel: None.
Introduction: Nonalcoholic fatty liver disease (NAFLD) and Type 2 diabetes mellitus (T2DM) commonly exist together and have been regarded as a manifestation of metabolic syndrome. But there are limited studies showing prevalence and association of NAFLD with T2DM patients in US populations. Aims and Objective: Primary outcome of the study was to identify the prevalence and association of NAFLD amongst patients with T2DM amongst the US populations. Methods: A cross-sectional study was performed using the National Health and Nutrition Examination Survey database from 2015 to 2018. Adults with diagnosis of NAFLD and non-NAFLD were identified. We ran univariate analysis using Mann Whitney U test and chi-square test. Multivariable survey logistic regression analysis was performed to find out the association between NAFLD and T2DM. Results: Out of a total 275,968 people, 0.26% had NAFLD. Older population (median: 62 years), male, Mexican American, and people with median household income &gt;$100,000 had a higher prevalence of NAFLD. The diagnosis of NAFLD (40.31% vs 14.23%; p&lt;0.0001) was more prevalent amongst patients with T2DM in comparison to those without NAFLD. In regression analysis, T2DM patients had significantly higher odds of having NAFLD (aOR: 10.40, 95%CI: 10.37- 10.42, p&lt;.0001, c=0.736). Conclusion: Long term follow-up, early identification, and prompt treatment may mitigate the burden of NAFLD in T2DM patients.
Presentation: Thursday, June 15, 2023
THU356 Muscle Pain In A Diabetic: Think Outside The Box
Authors: Ellangovan Rithikaa , Rizk Michelle-Ashley , Singh Vinita , Sherpa Chheki 
Published: October 2023

Abstract
Disclosure: R. Ellangovan: None. M. Rizk: None. V. Singh MD: None. C. Sherpa: None.
Introduction: Stiff person syndrome (SPS) is a rare immunological disorder associated with GAD antibody-spectrum disorders and characterized by rigidity and painful muscle spasms. SPS has a prevalence of 1-2 cases per million and affects females more than men. We present a case of SPS who was admitted for progressive muscle pain and rigidity causing impaired ambulation. Case Presentation: A 60-year-old female with a two-year history of type 2 diabetes, Graves' disease was diagnosed with acral lentiginous melanoma of the left foot. One month after Nivolumab immunotherapy, she converted to type 1 diabetes with low C-peptide and positive GAD antibody. She was admitted with severe muscle pain and spasms in her lower extremities and trunk, debilitating enough to make her bedbound. Her muscle strength and sensory function were intact. MRI of thigh was concerning for myositis versus diabetic myonecrosis. She was initiated on NSAIDs with no improvement. Core muscle biopsy revealed necrosis and granulation tissue with no evidence of malignancy. Extensive work up including myositis panel and myasthenia gravis panel were negative. The presence of GAD antibodies and no improvement to NSAIDs, prompted suspicion for SPS. The patient declined lumbar puncture (LP) for further evaluation. Diazepam showed mild improvement. Due to persistent severe symptoms, she was treated with IVIG for 5 days that resulted in marked improvement. Discussion: There is no gold standard test for definitive diagnosis of SPS. Classic features of SPS include muscle spasms, pain, and rigidity typically involving the trunk and lower extremities. There are GAD antibodies in serum and CSF and glycine receptor or amphiphysin antibodies. EMG study will show continuous motor unit activity in affected muscles. A robust response to muscle relaxants like GABA agonists and exclusion of alternative neurological disorder favors SPS. LP or EMG was not performed on this patient, yet she met other criteria including the presence of other GAD disorders like type 1 diabetes. Current recommended therapy for symptomatic relief includes GABA agonists or baclofen. If no improvement is noted, IVIG can be considered. Plasmapheresis and rituximab have been used with variable efficacy. Prognosis is variable and many patients experience disability despite combining multiple therapies. Hence it is crucial to have a high index of suspicion in GAD spectrum disorders for early recognition and prompt treatment.
Presentation: Thursday, June 15, 2023
THU357 A Case Of Recurrent Insulin-induced Edema In A Pediatric Adolescent Patient
Authors: Mora Calderon Guido Jesus , Aguirre Roxana L , Preston Debara 
Published: October 2023

Abstract
Disclosure: G.J. Mora Calderon: None. R.L. Aguirre: None. D. Preston: None.
Introduction: Insulin induced edema is a very rare complication seen after initiation of insulin therapy or after escalation of previous insulin regimen in patients with diabetes. The exact incidence of this condition is unknown. Insulin induced edema seems to have a female predominance and is associated primarily with patients who are underweight. The severity of insulin induced edema can range from mild localized peripheral edema to more severe and generalized complications, including cardiac failure and serosal effusions. There is a higher risk for severe complications in older patients with pre-existing cardiac, hepatic, or renal conditions. Usually, the course is benign and self-resolved without any intervention. Severe and prolonged cases have been reported to need adjuvant therapy (e.g diuretics or sympathomimetic agents) or sodium-restricted dietary regimens. Increasing blood glucose target with a decreased insulin regimen has been proposed as a possible option to prevent insulin induced edema. We present a 14 year-old-male patient with history of poor controlled type 1 diabetes mellitus and recurrent insulin-induced edema after strengthening of his insulin therapy. Case Presentation: A 14-year-old male with poorly controlled type 1 diabetes mellitus presented to the emergency with pitting edema of his face and hands that started a week after intensification of his insulin regimen. His weight increased from 73 kg to 84 kg in about 10 days. His vital signs at presentation were stable and besides the pitting edema, the rest of the physical examination was unremarkable. His mother reported a previous episode of edema that occurred approximately a year before this presentation and about a month after he was first diagnosed with diabetes mellitus. His most recent HbA1c was 14.4%. Patient was admitted for evaluation. Electrocardiogram, transthoracic echocardiogram, chest x-ray, and multiple laboratories (including a comprehensive metabolic panel, complete blood count, B-type natriuretic peptide, urine microalbumin, and thyroid function test ) came back all normal. The edema slowly improved and was eventually discharged. No adjuvant therapy was needed during his hospitalization. Conclusion: The diagnosis of insulin induced edema is primarily based on the exclusion of other etiologies. Most cases reported only one episode after initiation of insulin therapy or after escalation of previous insulin regimen, but it can happen multiple times as noted in our patient.
Presentation: Thursday, June 15, 2023
THU360 Hyperglycemic DKA In Patient On Monotherapy With SGLT-2 Inhibitor
Authors: Ahmed Samihah , Medina Mora Luis , Sanchez Ruiz Angelica , Poretsky Leonid 
Published: October 2023

Abstract
Disclosure: S. Ahmed: None. L. Medina Mora: None. A. Sanchez Ruiz: None. L. Poretsky: None.
Background: SGLT2 inhibitors have a rare but increasingly reported risk of euglycemic diabetic ketoacidosis. Hyperglycemic diabetic ketoacidosis is not an expected risk of SGLT-2 inhibitors. Clinical Case: 52-year-old male with history of type 2 Diabetes presented with progressive weakness, shortness of breath, nausea and vomiting worsening over 48 hours. He reported increased polydipsia and polyuria. Patient was found to have a blood glucose of 685 mg/dL associated with an anion gap of 28 mm/L and bicarbonate level of 6 mm/L. Beta hydroxybutyrate level was &gt;8.0 mmoL/L. He was diagnosed with hyperglycemic diabetic ketoacidosis, given intravenous isotonic fluid and started on an insulin drip. The anion gap closed and he was successfully transitioned off the insulin drip to a basal bolus regimen of insulin. The patient improved quickly without any complication. The patient was never on insulin therapy prior to admission. No obvious source of infection was discovered to precipitate the event. The patient had a 7-year history of diabetes and was only managed on oral medications at home. He was previously on Janumet 50-1000mg twice a day and changed to only dapagliflozin 10mg 9 months prior to the current episode. He never experienced ketoacidosis or hyperosmolar hyperglycemic state. Hemoglobin A1c was found to be 8.0%. He reported that his A1c levels were always less than 8%. Autoimmune workup for type 1 Diabetes was done. C-peptide level was found to be 1.5ng/mL. Patient appeared to have an adequate insulin level despite the recent event of diabetic ketoacidosis. Patient was discharged on 10 units of Glargine® at bedtime and 3 units of Lispro® before meals. He was given glucometer teaching with an appointment for endocrine follow up. During follow up Glutamic Acid decarboxylase, Islet cell, Insulin and Zinc 8 transporter antibodies have come back negative. Patient is being planned for transition to oral antihyperglycemic agents which will not include an SGLT2 inhibitor. A MODY panel is pending results for further evaluation. Conclusion: Monotherapy of SGLT-2 inhibitors appears to not only have a risk of euglycemic diabetic ketoacidosis but also a risk of hyperglycemic diabetic ketoacidosis in type 2 diabetics. In this case we presented a case of hyperglycemic diabetic ketoacidosis in a type 2 diabetic on therapy with dapagliflozin.
Presentation: Thursday, June 15, 2023
THU363 Misdiagnosing Latent Autoimmune Diabetes Mellitus In Adults: A Case Report
Authors: Rafat Ummara , Akhter Wajeeha , Alshantti Raeda , Gilden Janice L 
Published: October 2023

Abstract
Disclosure: U. Rafat: None. W. Akhter: None. R. Alshantti: None. J.L. Gilden: None.
Background: Latent Autoimmune Diabetes Mellitus (DM) in Adults (LADA) is often misdiagnosed as Type 2 DM. This can lead to increased risk of complications. Therefore, knowledge and awareness of LADA is essential. LADA is diagnosed based on three features, age greater than 35 years, presence of antibodies to pancreatic islet cell antigens (Glutamic Acid Decarboxylase GAD, Insulinoma antigen-2 IA-2A, Zinc Transporter 8 ZnT8A) and lack of insulin requirement for at least 6 months after diagnosis. It is important to diagnose LADA early, so that patients can be started on insulin earlier, thereby achieving better glycemic control and preserving residual beta cell function. Case Presentation: We present the case of a 44-year-old female of mixed African American and Greek ethnicity with a history of DM complicated by nephropathy, hypertension, obesity, acne and uterine fibroids. She was diagnosed with Type 2 DM at age 36 from routine screening with a HbA1c of 6.9% and started on Metformin by primary care provider. Family history was significant for transient postpartum hypothyroidism in her mother, and DM in both maternal and paternal grandparents. She was unable to tolerate Metformin due to gastrointestinal side effects and was switched to Insulin Detemir therapy one year later. She first presented to the endocrine clinic for evaluation and management of abnormal thyroid function tests with symptoms of weight loss, excessive hair fall, anxiety, and palpitations. Vital signs: Blood pressure 146/65 mmHg, Heart rate 89 bpm, Respiration 14 breaths/min, BMI 31 kg/m2. Physical examination was significant for marked edema of eyelids, but no thyromegaly or tremors, and marked acanthosis nigricans. Laboratory tests were consistent with Grave’s disease with TSH less than 0.005 uIU/mL (n= 0.358-3.74), free T3 22.93 pg/mL (n=2.18-3.98), free T4 4.63 ng/dL (n=0.76-1.46) and positive TSI of 291%. (n&lt;140). The patient was started with methimazole therapy. GAD 65 was found to be positive &gt;250 IU/mL (n&lt;5) and islet cell antibodies were negative. A revised diagnosis of LADA was made. The co-existence of Grave’s disease enabled reclassifying the type of her DM. Conclusion: Type 1 diabetes mellitus or autoimmune diabetes mellitus should always be ruled out if the clinical picture does not match with type 2 Diabetes Mellitus or in a relatively young patient. Our case aims to increase awareness of Autoimmune Polyendocrine syndrome, which occurs as a result of loss of immune tolerance, leading to impairment of multiple endocrine glands.
References: Standards of Care in Diabetes—2023 Diabetes Care 2023;46(Suppl. 1):S5-S9 Volume 46 Issue Supplement_1 | Diabetes Care | American Diabetes Association (diabetesjournals.org)
Presentation: Thursday, June 15, 2023