bluuebunny/crossref_metadata_2025_split huggingface dataset:
OR24-05 High Waist Circumference Is Strongly Predictive Of Hepatic Steatosis And Significant Fibrosis
Authors: Janakiram Nikhila , Puri Sadhana , Thirumalai Arthi 
Published: October 2023

Abstract
Disclosure: N. Janakiram: None. S. Puri: None. A. Thirumalai: None.
Vibration-controlled transient elastography (TE) can measure controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) in non-alcoholic fatty liver disease (NAFLD) patients. A high skin-to-capsule distance can challenge the accuracy of this imaging technique. Therefore, high waist circumference (WC), a known risk factor for NAFLD, can hamper assessment in high-risk patients. Studies investigating the relationship between WC and TE measurements have yielded conflicting results. We used the 2017-2018 National Health and Nutrition Examination Survey (NHANES) data to explore this relationship in a large cohort of the general population. We hypothesized that high WC would be associated with (1) higher failure rate for completion of TE, (2) worse CAP and LSM measurements and (3) be predictive of presence of steatosis and significant fibrosis. We summarized the primary reason for incomplete TE in normal and high WC participants of male (M; WC ≥ 102 cm = high) and female (F; WC ≥ 88 cm = high) gender. We compared mean CAP and LSM between normal and high WC participants using unpaired t-tests. We calculated area under receiver operator curve (AUROC) for WC predicting presence of steatosis (CAP ≥248 dB/m) and significant fibrosis (LSM ≥8 kPa) and compared this with fibrosis-4 (FIB-4) and NAFLD fibrosis scores (NFS). We analyzed the 5757 patients (2880 F, 2877 M) with complete or partial TE status, based on WC. Proportion of patients with partial TE status was higher in those with high WC (8.9% F, 9% M) than normal WC patients (6.5% F, 6.4% M). We analyzed the 446 patients with partial TE status (231 F, 215 M) by cause. The proportion of patients who were unable to complete TE, either due to an IQR/medium &gt; 30% or not having 10 valid measurements among the high WC population (66%) was significantly higher than those with normal WC (23%), in both women (X2 (1, n=231) = 29.63; p&lt;.001) and men (X2 (1, n=215) = 49.43; p&lt;.001).Among those with complete TE (n=2313; 1090 M, 1223 F), mean CAP was significantly higher (p&lt;0.001) in high WC patients (308 dB/m M, 278 dB/m F) compared to normal WC patients (250 dB/m M, 225 dB/m F). Mean LSM was significantly higher (p&lt;0.001) in high WC patients (6.8 kPa M, 5.7 kPa F) compared to normal WC patients (5.7 kPa M, 4.5 kPa F). The AUROC for WC predicting presence of steatosis was 0.77 in F and 0.80 in M (p&lt;0.001 for both). The AUROC for WC predicting the presence of significant fibrosis (≥8 kPa) was 0.73 in F and 0.71 in M (p&lt;0.001 for both). In AUROC analyses, WC performed better than FIB-4 and NFS in predicting presence of significant fibrosis and steatosis. Therefore, we conclude that high WC is more likely to result in an incomplete TE, but among those with a valid exam, it is highly predictive of presence of steatosis and significant fibrosis.
Presentation: Saturday, June 17, 2023
THU245 Association Between Sleep Duration And Incident Diabetes Mellitus In Healthy Subjects: A 12-year Longitudinal Cohort Study
Authors: Kim Wonjin , Hye Huh Ji 
Published: October 2023

Abstract
Disclosure: W. Kim: None. J. Huh: None.
Objective: Previous studies demonstrated that inadequate sleep, including the deprivation of absolute sleep duration and poor sleep quality, was associated with a higher risk of type 2 diabetes mellitus (DM) and obesity. This study aimed to investigate whether sleep duration and/or quality is associated with incident DM. Methods: The study population consisted of participants in the ongoing Korean Genome and Epidemiology Study (KoGES)-Ansung and Ansan Cohort Study, a rural, community-based, prospective study. A total of 8,816 of 10,030 healthy participants were enrolled in a prospective cohort study. DM was diagnosed as fasting glucose ≥126 mg/dL or 2-h post-loading glucose ≥200 mg/dL. Sleep du-ration and quality questionnaires were completed. Sleep duration was classified into four groups: 6 &lt;, 6-7, 8-9, 9 h/day. Sleep quality was assessed in participants with sleep duration of &lt; 10 h/day using the Epworth Sleepiness Scale (ESS) which measures an excessive daytime sleepiness in individuals. Results: During the 14-year follow-up period, 18% (1630/8816) were diagnosed with DM. A U-shaped relationship was observed between sleep duration and incident DM, with the highest risk observed when sleep duration was 10 ≥ h/day (Hazard ratios (HR) 1.65 [1.25–2.17]). This group exhibited decreased insulin glycogenic index, a marker of insulin secretory function, during the study period. Among study participants who slept less than 10 h/day, the risk of incident DM increased when the ESS score was &gt; 10. Conclusion: We found that the association between sleep duration and incident DM was U-shaped; both short (≤5 h) and long (≥10 h) sleep duration were associated with an increased risk for the occurrence of incident DM. When sleep duration was 10 h or longer per day, there was a tendency to develop DM due to decreased insulin secretory function. Even if the sleep duration is less than 10 h, the likelihood of developing diabetes is greater when the quality of sleep decreases.
Presentation: Thursday, June 15, 2023
THU322 Lower HbA1c Is Associated With Lower In-Hospital Mortality In Patients With COVID-19
Authors: Tsikala Vafea Maria , Stefanovic-Racic Maja 
Published: October 2023

Abstract
Disclosure: M. Tsikala Vafea: None. M. Stefanovic-Racic: None.
Introduction/Aim: Diabetes has been proven to be a risk factor for worse outcomes in patients with COVID-19. Several studies have shown that poor glycemic control during hospitalization with COVID-19 is associated with higher mortality. However, the association between a long-term glycemic control and outcomes has yet to be clarified, with some studies reporting no association. The aim of this study is to determine the association between glycosylated hemoglobin (HbA1c) and in-hospital mortality in patients with COVID-19. Methods: Pubmed, Embase and Web of Science databases were searched until 11/15/2022, for studies examining the association between HbA1c level and mortality in hospitalized patients with COVID-19. A random-effects meta-analysis was performed. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots. Results: Among 4,142 results, 22 studies were included in the final analysis with a total of 11,998 patients. In the primary analysis, in studies comparing outcomes in patients using HbA1c as a dichotomous variable using specific cutoff values, lower Hba1c was associated with lower in-hospital mortality [odds ratio (OR) 0.52, 95% confidence interval (CI) 0.37-0.72]. Heterogeneity was substantial (I2 78%). When only patients with diabetes were included in the analysis, the association remained statistically significant (OR 0.70, 95% CI 0.51-0.98). In the subgroup analysis, the association remained statistically significant in studies using as cutoff the HbA1c value of 6.5% (OR 0.34, 95% CI 0.15-0.77) and 7% (OR 0.54, 95% CI 0.32-0.90). The association did not remain statistically significant with greater HbA1c cutoff values; 7.5% (OR 1.09, 95% CI 0.91-1.30) and &gt;= 8% (OR 0.78, 95% CI 0.33-1.82). In the secondary analysis, in studies using HbA1C as a continuous variable, HbA1c level did not have a statistically significant association with in-hospital mortality, either in univariate (OR 0.97, 95% CI 0.92-1.03) or multivariate analyses (adjusted OR 1.00, 95% CI 1.00-1.01). Conclusion: A better glycemic control prior to hospitalization, as reflected by lower HbA1c, is associated with lower in-hospital mortality in patients with COVID-19.
Presentation: Thursday, June 15, 2023
THU381 A Case of Severe Type B Insulin Resistance Successfully Treated With Combined Immunosuppressive Therapy
Authors: Singh Sumal Amit Kartar , Santos Martinez Dorothy 
Published: October 2023

Abstract
Disclosure: A.K. Sumal: None. D.S. Martinez: None.
Background: Type B insulin resistance is a rare autoimmune disorder caused by autoantibodies against the insulin receptor and is characterized by markedly high insulin requirements, severe catabolism, and a mortality rate over 50%. Clinical Case: A 50-year-old woman with Sjogren’s syndrome and a one-year history of diabetes treated with insulin presented with diabetic ketoacidosis (DKA) and was found to have type B insulin resistance. Initial laboratory workup demonstrated DKA with a blood glucose of 464 mg/dL (n: 65–99 mg/dL), CO2 8 mmol/L (n: 20–30 mmol/L), anion gap 16 (n: 8–12), pH 7.08 (n: 7.30–7.40) on venous blood gas, 2+ ketonuria, and a hemoglobin A1c of 11.7% (n: &lt;5.7%). Additional workup revealed negative glutamic acid decarboxylase-65, insulin antigen-2, and insulin antibodies, positive C-peptide 2.7 ng/mL (n: 1.1–4.3 ng/mL), and elevated adiponectin 41 ug/mL (n: 5–28 ug/mL). Her physical exam was notable for 100 lb weight loss and extensive acanthosis nigricans, facial acne, and hirsutism. She was started on IV insulin infusion with resolution of her DKA but required more than 5000 units of insulin per day to obtain glycemic control. Due to the suspicion of type B insulin resistance, she was treated with metformin 1000 mg twice daily and pioglitazone 45 mg daily to reverse her hypercatabolic state and combined immunosuppressive therapy consisting of 2 cycles of rituximab 750 mg/m2 infusion, cyclophosphamide 100 mg daily, and dexamethasone 40 mg for 4 days administered 14 days apart based on a 2018 NIH protocol. Her serum was sent for confirmatory insulin receptor autoantibody testing, which is pending. Over the next 30 days, her insulin requirements improved immensely, and she was ultimately discharged without insulin in clinical remission. To prevent recurrence and hypoglycemia associated with low titers of insulin receptor autoantibodies, she was started on azathioprine 100 mg daily as maintenance therapy. Three months later, she was seen in endocrine clinic in sustained remission with a hemoglobin A1c of 6.0% and resolution of her acanthosis nigricans and hyperandrogenism. Review of her continuous glucose monitor showed no episodes of hypoglycemia. Conclusion: This rare case demonstrates the successful treatment of type B insulin resistance using metformin, pioglitazone, and combination immunosuppressive therapy with rituximab, cyclophosphamide, and pulse-dose steroids, followed by maintenance azathioprine. With a mortality rate over 50%, the use of combined immunosuppressive therapy has transformed this condition into a curable form of diabetes and should be recommended in all patients with type B insulin resistance.
Presentation: Thursday, June 15, 2023
THU383 “My Hands Are Always Stiff”: A Common But Underrecognized Mimicker Of Inflammatory Arthritis.
Authors: Iqbal Iqra , Minalyan Artem , Alam Khan Muhammad Atique 
Published: October 2023

Abstract
Disclosure: I. Iqbal: None. A. Minalyan: None. M. Khan: None.
Introduction: Inflammatory arthropathies are often identified in patients by their characteristic patterns, including symmetric small joint involvement, joint stiffness that can improve with physical activity, and others. However, it is crucial to address comorbidities and their impact on symptom presentation when assessing these patients. Here we present a case of a relatively common but underrecognized mimicker of inflammatory arthropathies. Case: A 63-year-old man with Type 1 Diabetes Mellitus (DM1) and seronegative rheumatoid arthritis (RA) was referred to a rheumatology clinic by his family physician to manage RA. He was previously treated with prednisone and methotrexate for six months for presumed seronegative rheumatoid arthritis without any relief. He reported chronic pain and stiffness in his joints: wrists, metacarpophalangeal (MCP), proximal and distal interphalangeal (PIP and DIP) joints, ankles, and feet. His symptoms were worse in the morning. However, on further questioning, he admitted that the stiffness did not improve throughout the day. He denied joint swelling or redness over the affected joints. On exam, his hand joints had significant stiffness. We obtained hand radiographs which did not show erosive changes or significant joint space narrowing. He had negative rheumatoid factor (RF), normal anti-cyclic citrullinated peptide (CCP) antibodies, and antinuclear antibody (ANA) levels, which ruled out the diagnosis of rheumatoid arthritis. A detailed physical exam demonstrated a positive “prayer sign” and “tabletop sign.” Further lab review showed that his hemoglobin A1c (HbA1C) had been ranging between 8% to 10% over several years. Eventually, the patient was diagnosed with limited joint mobility due to the poorly controlled DM1. We discontinued his methotrexate and referred him to an endocrinologist to manage the uncontrolled DM1. He was referred to physical therapy for hand stretching exercises. After six months of treatment, his symptoms improved but did not resolve completely. Conclusion: It is essential to identify the impact of diabetes on the musculoskeletal system. Limited joint mobility, previously known as diabetic cheiroarthropathy (DCA), is a common but frequently missed manifestation of poorly controlled diabetes. It is characterized by a limited ability to flex or extend the MCP and IP joints. It may or may not be painful and can progress to fixed flexion contractures of the finger joints. Early recognition is essential for correct diagnosis. Treatment is with tighter glycemic control and physical therapy.
Presentation: Thursday, June 15, 2023
THU385 Refractory Hyperglycemia As Main Presenting Symptom In A Patient With Acromegaly
Authors: Rave Talia , Vidovic Jovana , Gu Yuwei 
Published: October 2023

Abstract
Disclosure: T. Rave: None. J. Vidovic: None. Y. Gu: None.
Acromegaly is a rare disorder caused by the overproduction of growth hormone (GH) from an anterior pituitary adenoma. GH regulates glucose control and about 10% of patients with acromegaly can have complications of hyperglycemia. GH stimulates hepatic release of insulin-like growth hormone-1 (IGF-1), which increases gluconeogenesis and lipolysis and decreases glucose uptake throughout the body. The increase in gluconeogenesis and decrease in glucose uptake results in hyperglycemia. The excess release of fatty acids increases insulin resistance. In this case report we present a case of hyperglycemia resistant to multiple modes of medical management with limited acromegaly features found to have acromegaly induced hyperglycemia. A 58-year-old male with a past medical history of type II diabetes mellitus, hypertension, and obesity presented to the endocrinology clinic with treatment resistant hyperglycemia. The patient also endorsed having progressive carpal tunnel symptoms. He had been using an insulin pump and requiring 3 or more boluses per day for the last 6 months. Trulicity was added in addition to current insulin pump therapy, however, sugars remained elevated with an unimproved A1c level of 9% and a fructosamine level of 538 µmol/L correlating to an A1c of 10.8%. An IGF-1 level was sent to rule out acromegaly in the setting of carpal tunnel symptoms. The IGF-1 resulted in 580 ng/mL with a z-score of +5.1. The patient underwent a GH suppression test with a glucose load which showed a significantly elevated nadir GH level of 26.3 ng/mL. Of note, the patient did not have other acromegaly symptoms such as frontal bossing, ring or shoe enlargement, coarse facial features, headaches or vision changes. An MRI pituitary was obtained which was notable for an enlarged pituitary gland with heterogeneous signal, measuring approximately 2.0cm CC x 1.5cm AP x 1.7cm TV, with the pituitary stalk deviated to the left. At this time the intervention for hyperglycemic therapy shifted. The patient was started on octreotide and referred to neurosurgery for transsphenoidal surgery. The pathophysiology of type II diabetes is complex and multifaceted. Additionally, secondary causes of hyperglycemia must be considered in refractory cases, such as in this patient. This case highlights the importance of considering acromegaly and other hormonal conditions in the treatment of patients with uncontrolled hyperglycemia, even in otherwise asymptomatic patients.
Presentation: Thursday, June 15, 2023
THU392 Type B Insulin Resistance: A Rare Cause Of Hypoglycemia
Authors: Zahoor Bhat Salman , Sidhaye Aniket , Hekmat Hamrahian Amir 
Published: October 2023

Abstract
Disclosure: S.Z. Bhat: None. A. Sidhaye: None. A.H. Hamrahian: None.
Introduction: Non-diabetic hypoglycemia in patients with diabetes mellitus is rare. Type B insulin resistance syndrome (TBIRS), caused by insulin receptor antibodies, presents with severe insulin resistance, but can uncommonly result in a hypoglycemic picture. Clinical Case: A 59-year-old woman with a history of SLE, T2DM, and primary hyperparathyroidism was admitted for acute confusion and found to have a POC glucose of 30 mg/dl. Her symptoms improved after IV glucose administration. She was on a stable basal-bolus insulin regimen of 0.8 U/kg/day and had unintentional 100-pound weight loss over 1 year. Significant exam findings included BMI of 29 kg/m2, gingival hyperplasia, and acanthosis nigricans. Aside from insulin, she took no medications strongly associated with hypoglycemia. Labs including CBC, CMP, TFTs, and morning cortisol were normal. HbA1C and adiponectin levels were 7.7%, and 28 µg/ml (5-28), respectively. Given the suspicion of exogenous insulin-mediated hypoglycemia, only correctional insulin was used during hospitalization. She had a repeat hypoglycemic episode on the 2nd day with minimal insulin use. A 72-hour fasting test showed a whole blood glucose of 44 mg/dL with concurrent serum C-peptide of 1.72 ng/mL, serum insulin 55 mIU/L and pro-insulin 21.9 pmol/L 12 hours into fasting. MRCP showed an 11 mm cystic lesion in the pancreas and widespread lymphadenopathy. The CGM noted significant fasting and post-prandial hypoglycemia. Diagnosis of insulinoma was considered unlikely due to persistent post-prandial hyperglycemia. Oral hypoglycemic panel and insulin autoantibodies were negative. The patient’s history of SLE, high-normal adiponectin, history of hyperglycemia and the presence of acanthosis nigricans favored work-up for insulin resistance syndromes. Due to the non-availability of insulin receptor antibody testing in the US, blood work was sent to Dr. Lutz Schomburg’s lab at Institute for Experimental Endocrinology, Berlin, Germany. The patient’serum was positive for insulin receptor antibodies, tested via an immunoassay technique, with elevated binding index (BI) of 248, 251 and 247 on 3 different samples of the patient, and normal binding index in the control sample, leading to the diagnosis of type B insulin resistance syndrome (BI &gt;3 is positive, &gt;10 indicates high positivity). The patient was treated with diet modification and CGM use, with improvement in the frequency of hypoglycemic episodes. She declined immunomodulation therapy. Conclusion: Hypoglycemia is an uncommon presentation of TBIRS and should be considered in the differential of non-diabetic hypoglycemia, particularly in patients with a history of auto-immune disease. The mechanism for hypoglycemia is purported to be an insulin-mimetic effect of insulin receptor antibodies at low titers.
Presentation: Thursday, June 15, 2023
FRI618 Lifetime Risk Of Nontraumatic Lower-extremity Amputation
Authors: Ding Ning , Mok Yejin , Salameh Maya , Tang Weihong , Selvin Elizabeth , Butler Kenneth R , Matsushita Kunihiro 
Published: October 2023

Abstract
Disclosure: N. Ding: None. Y. Mok: None. M. Salameh: None. W. Tang: None. E. Selvin: None. K.R. Butler: None. K. Matsushita: None.
Introduction: Nontraumatic lower-extremity amputation (NLEA) is mainly caused by diabetes and peripheral artery disease. Although the annual incidence of NLEA is generally well-documented, no lifetime risk estimates are currently available. Furthermore, it is unknown whether the estimates vary by sociodemographic characteristics. Methods: In 14,108 ARIC participants aged 45-64 at baseline (1987-89), we estimated the cumulative incidence of NLEA (identified from discharge ICD codes) in the lifespan from age 50 through 80 using Fine and Gray’s proportional subhazards models accounting for the competing risk of death. We also explored the lifetime risk of NLEA by sex, race, annual household income, and in participants with diabetes. Additionally, we estimated the cumulative mortality among participants with and without NLEA using Kaplan-Meier analysis, in the scheme of a 1:2 matched cohort study. Results: There were 226 NLEA cases during a median follow-up time of 30 years. The estimated overall lifetime risk of NLEA from 50 years of age was 1.5% (95% confidence interval [CI], 1.3%-1.7%). The lifetime risk was highest in Black men (4.2% [3.1%-5.5%]), followed by Black women (2.7% [2.1%-3.5%]), White men (1.1% [0.8%-1.5%]), and White women (0.7% [0.5%-0.9%]). When further categorized by income, Black men with low income showed the highest lifetime risk (5.2% [3.7%-7.0%]), while White men with high income had a lifetime risk of 0.9% (0.6%-1.2%). Diabetes drastically increased the risk of NLEA by 5-fold in each race-sex group. Black men with diabetes have a 14% risk of developing NLEA in their lifetime. In the matched cohort study, we included 225 participants with NLEA and 450 without NLEA. The 1-year mortality was 30.9% (25.3%-37.4%) among those with NLEA and 4.1% (2.6%-6.4%) among those without NLEA, while the 10-year mortality was 83.5% (77.7%-88.6%) among those with NLEA and 38.9% (34.2%-44.1%) among those without. Conclusions: In this community-based cohort, 3%-4% of Black individuals experienced NLEA during their lifetime, while 1% of White individuals did. The lifetime risk was enhanced in people with low income and diabetes. Those with NLEA had greater short-term and long-term mortality than those without. Future public health efforts to prevent limb loss should prioritize racial minorities, those with low socioeconomic status, and diabetes.
Presentation: Friday, June 16, 2023