bluuebunny/crossref_metadata_2025_split huggingface dataset:
PSAT277 Glucocorticoid Therapy for Management of Hypoglycemia in the context of Non-Islet Cell Tumor-Induced Hypoglycemia
Authors: Agarwal Rahul , Rodriguez Ortega Susel , Vasquez Mendez Juan 
Published: November 2022

Abstract

Background
Non-islet cell tumor-induced hypoglycemia (NICTH) is a rare paraneoplastic syndrome which can cause recurrent hypoglycemia. There is no clear standard of care for management of hypoglycemia. Often, these patients have high morbidity and therefore surgical tumor resection is not always possible. Clinical case: This is the case of a 69 year-old male presenting with altered mental status in the context of hypoglycemia without clear etiology with an initial serum glucose level of 32 mg/dL (normal range 60-100 mg/dL) which quickly corrected after administration of intravenous glucose. He was found to have a large bowel obstruction with CT abdomen revealing an underlying neoplasm. Biopsy of suspected lesion on colonoscopy revealed colorectal adenocarcinoma. Repeated episodes of hypoglycemia complicated by seizures required inpatient management. Workup included serum insulin level which resulted in suppressed level (&lt;1. 0 uU/mL, normal range 1.9-23. 0 uU/mL), low c-peptide level (0.1 ng/mL, normal range 1.1-4.4 ng/mL), low beta hydroxybutyrate level (0. 07 mmol/L, normal level &lt;0.3 mmol/L), cortisol level of 43.7 mcg/dL, undetectable insulin like growth factor-1 (IGF-1) level (&lt;10 ng/mL, normal range 59-230 ng/mL) and low insulin like growth factor-2 (IGF-2) level (66 ng/mL, normal range 333 - 967 ng/mL). IGF2: IGF1 ratio was 66 (ratio &gt;10 is indicative for diagnosis of non-islet cell tumor hypoglycemia). Due to extremely poor oral intake and recurrent episodes of hypoglycemia despite continuous dextrose infusion, the patient was started on 20 mg prednisone daily. Eventually, 40 mg of intravenous methylprednisolone in addition to dextrose infusion was needed as maintenance therapy effectively preventing hypoglycemia. Given his poor functional status, the surgical and oncology team decided he was no longer a surgical or chemotherapy candidate. Eventually, palliative medicine was consulted and the patient was transitioned to comfort care with a plan for outpatient hospice.

Conclusion
NICTH should be suspected in any patient with hypoglycemia without clear etiology, especially if there are suggestions to NICTH such as known malignancy or newly diagnosed mass. Once NICTH is identified and a primary tumor is found, complete tumor resection represents ideal management, however, not always attainable. In such cases, dextrose infusion might be insufficient to prevent hypoglycemia and is not always the preferred option given the required long-term venous access. In these circumstances, early high dose glucocorticoids are safe and appear to successfully prevent hypoglycemic events.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSUN134 Loss of Glp-1r Signaling in the β-Cell Impairs Adaptive Proliferation and Insulin Secretion
Authors: Olvera Angela , Saghafi Samuel , de Souza Arnaldo , Tang Jaiyin , Yadev Amanjot , Meyer Riley , Davis Dawn B 
Published: November 2022

Abstract
Type 2 diabetes mellitus is characterized by insulin resistance and loss of pancreatic b-cell mass. b-cells are located in the pancreatic islets and secrete insulin. Though many therapies exist that address insulin resistance and to augment b-cell insulin secretion, there is a critical need to find therapies to preserve b-cell mass in order to decrease the incidence and severity of diabetes. In non-diabetic obesity, an early adaptive response to insulin resistance is increased b-cell proliferation. This compensatory mechanism leads to increased b-cell mass and increased insulin secretion from b-cells. This increase in b-cell mass is seen in as little as 4 days of high fat diet (HFD) feeding in murine models.
A promising therapeutic for the preservation of b-cell mass is glucagon-like peptide-1 receptor (Glp-1r) agonists. The ability of GLP-1 to stimulate b-cell proliferation and inhibit apoptosis is largely based on studies using pharmacologic treatment, but the importance of GLP-1 in b-cell mass regulation in normal physiology or pathophysiology has not been well studied. Notably, GLP-1 is secreted from alpha cells in the local islet environment and this paracrine signaling pathway is important for islet function. The goal of this work is to investigate the contribution of b-cell Glp-1r signaling to b-cell mass regulation in the metabolic stress condition of a one-week HFD. We hypothesize that b-cell Glp-1r signaling is necessary for the compensatory mechanisms needed to maintain glucose homeostasis during metabolic stress conditions and that lack of b-cell Glp-1r will lead to decreased proliferation of b-cells. Understanding the role of β-cell Glp-1r signaling in adaptive b-cell mass expansion will allow for development of new strategies to augment β-cell mass in type 2 diabetes.
We used a newly generated murine model with a b-cell specific knockout of Glp-1r, where the Ins1-Cre knock-in transgene drives recombination in b-cells. Glp-1r fl/fl mice (WT) and Glp-1r fl/fl – Ins1Cre mice (KO) were fed a HFD for one week. There was a trend toward elevated fasting (171+/-29 mg/dl vs 205+/-36 mg/dl, p=0.0475, n=9) and non-fasting blood glucose (195+/-24 mg/dl vs 216+/-40 mg/dl, p=0.0537, n=18) and impaired glucose tolerance in the KO mice. Notably, we found that insulin secretion in response to intraperitoneal glucose is impaired in KO mice. KO mice have a blunted proliferation response to a 1-week HFD stress, as measured by Ki67 mRNA levels (1.5-fold induction of Ki67 in WT vs. 0.6-fold induction in KO, p=0.0167, n=8-10). b-cell proliferation will also be measured by immunofluorescent image analysis of whole pancreas sections. These data suggest there is a critical role for b-cell Glp-1r signaling in the early proliferative response of b-cells in response to metabolic stress.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN138 Demonstration of Progressive Beta-Cell Failure in Familial Partial Lipodystrophy
Authors: De Freitas Maria Foss , Neidert Adam , Schill Rebecca , Maung Jessica , Rosenberg Drake , MacDougald Ormond , Oral Elif 
Published: November 2022

Abstract

Background
Familial Partial Lipodystrophy Type 2 (FPLD2) is an autosomal dominant disorder caused by inherited mutations on the LMNA gene, typically on exon 8 and 11. Insulin resistance and diabetes mellitus are common clinical manifestations in patients with partial lipodystrophy. Despite aggressive treatment aiming reduction in insulin resistance, patients usually require insulin treatment, highlighting the presence of insulin secretion defects. The sequence of events to develop metabolic derangement is not well studied. This study aims to compare the metabolic changes and insulin secretion in two generations of patients with FPLD2.

Methods
In a longitudinal study, we are studying the metabolic and morphometric changes in younger patients carrying the mutation who have not fully expressed the phenotype and comparing their findings to their affected older relatives. In the first year of the study, six affected young patients (age: 17±4 years, 4F/2M) and four affected older relatives (age: 46±7 years, all-female) have completed a 5-hour OGTT with 75g of glucose to determine the metabolic parameters at 30-minute intervals as well as the area under the curve (AUC) for these parameters.

Results
Patients in the younger group did not have a clinical diagnosis of diabetes (mean HbA1c of 5.3±0.3%), while all patients in the older generation had the diagnosis of diabetes mellitus with higher HbA1c (7.9±3.1%, p=0.05). Younger patients showed a lower AUC for glucose (28703±12037 mg/dL/min), triglycerides (38820±15305 mg/dL/min, p&lt;0.05)) and free fatty acids (FFA) (78±29mmol/L/min) compared to older affected patients (glucose AUC: 67563±39089 mg/dL/min; triglycerides AUC: 96461±39989 mg/dL/min; FFA AUC: 159±125 mmol/L/min). However, insulin and C-peptide AUC were higher in the younger group compared to the older generation (insulin AUC: 60664±66802 vs. 29331±23341 mcU/mL/min; C-peptide AUC: 3466±1646 vs. 2548±1391 mg/L/min). The change in C-Peptide in the first 30 min post glucose was significantly higher in the younger group compared to the older group (12±1.8 vs. 5±4 mg/L; p&lt;0.05). Insulin secretion during the first 30 min of the test was numerically higher in the younger group versus the older group (213±90 vs. 90±115 mcU/mL).

Conclusion
Our data (albeit limited) show that the clinical manifestation of diabetes mellitus in older patients with FPLD2 is associated with impairments in insulin secretion, therefore highlighting the importance of beta-cell failure in the development of diabetes mellitus in this population. These data draw attention to the need for further investigation of the pancreatic endocrine dysfunction to treat and better understand diabetes mellitus in this population. Strategies to address just insulin resistance may not be sufficient to prevent the development of diabetes in the long run.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN139 Leukemoid Reaction in Severe Diabetic Ketoacidosis: An Indicator of Severity or Predictor of Infection?
Authors: Sarigumba Marion , Gonzales Cecilia 
Published: November 2022

Abstract

Background
Acute infectious illness can precipitate episodes of ketoacidosis in patients with diabetes mellitus. For this reason, a diligent search for a focus is essential in the initial evaluation of patients with DKA since patients often appear ill and may have non-specific symptoms.

Clinical Case
An 18-year old Filipino with Type 1 Diabetes Mellitus sought consult due to abdominal pain. He is on premixed NPH/regular insulin twice daily but was lost to follow-up due to the COVID-19 pandemic. He has no other comorbidities but asserted a prior history of poor compliance with both diet and insulin therapy besides an erratic sleep-wake cycle. Prior to consult, he reported 5 episodes of vomiting associated with generalized abdominal pain. Due to poor appetite, he missed due doses of insulin with subsequent worsening of condition.
On admission, he was lethargic with Kussmaul's breathing. Initial vital signs were stable. He had dry lips and oral mucosa, sunken eyeballs and generalized abdominal tenderness. COVID-19 PCR was negative. Serum lipase (8.79, n: 8-78) and CT scan of abdomen were likewise unremarkable. Initial CBG was HIGH with elevated ketones (5.4, n: &lt;0.6) and arterial blood gas revealed a pH of 7.0, pCO2 22, HCO3 incalculable, lactate 3.9, with high anion gap. The initial WBC was high (44.3×109/uL, n: 4.4-11) with 84% neutrophils, 10% lymphocytes, 1% metamyelocytes, and 5% monocytes. Hemoglobin (18.5 g/dl), hematocrit (51.7%) and platelet count (614k/uL) were also elevated. Peripheral blood smear revealed normal cell morphology. Urinalysis revealed elevated specific gravity, marked glycosuria and ketonuria, negative nitrites and leukocyte esterases. Blood specimen were obtained for culture. Therapy was instituted with intravenous fluids, insulin drip and broad spectrum antibiotics.
The following day, glucose was 218 mg/dl, pH 7.16, bicarbonate 7.8 meq/L, hematocrit 44%, WBC 25.21×109/uL and platelet count was 401k/uL. LAP score was requested but was unavailable. On the fourth hospital day, the patient was well and tolerating diet, with normalization of blood glucose, WBC 9.87 (85% neutrophils, 10% lymphocytes, 5% monocytes) and control of acidosis. Since cultures were negative and patient was afebrile, antibiotics were discontinued. He was discharged stable on with basal-bolus insulin.

Conclusion
The association between DKA and leukocytosis in the absence of infection is described in literature. Exact mechanism is unknown but may in part be attributed to increased catecholamine release in response to stress and hemoconcentration from marked dehydration. Studies show a statistically significant relationship between pH, bicarbonate and leukocytes which denotes that WBC in DKA can be an indicator of the severity of ketoacidosis rather than a predictor of infection.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN141 Suspected Lipodystrophy in a Thin Young Man With Type 1 Diabetes
Authors: Moats Sarah , Ahrari Bijan , Yu Kaylee Gayong , Nakhle Samer , Vernetti Nicholas 
Published: November 2022

Abstract

Introduction
Lipodystrophies are a group of exceptionally rare adipose disorders typified by complete or partial lack of adipose tissue. They come in two forms, congenital and acquired. Global prevalence is approximately 3 cases per million people. Despite their rarity, lipodystrophies often have common derangements, including, insulin resistance, decreased leptin, lipid abnormalities, and non-alcoholic fatty liver disease. Identifying and diagnosing these disorders is challenging as so few cases exist and may easily be confused for a variety of other illnesses.

Case
Our patient was a 21 year old African American Male with BMI of 14.0 kg/m2 (46.72 kg, 28.35 cm), with antibody proven type 1 diabetes mellitus diagnosed and extreme weight loss at age 12. His diabetes has been poorly controlled since diagnosis, with episodes of DKA, and a persistently elevated A1c. He has evidence of insulin resistance, requiring about 2.57 units per kilogram of insulin daily. In spite of this fasting blood glucose routinely exceeds 300 mg/dL. Physical exam significant for a generalized lack of adipose tissue. Most recent laboratory results showed: HbA1c &gt;14% (&lt;5.7%), fasting plasma glucose 419 mg/dL (70-99 mg/dL), c-peptide &lt;0.10 ng/mL (0.80-3.85 ng/dL), and GAD65 Ab 18 IU/mL (&lt;5 IU/mL). Interestingly patient also had a decreased leptin of 0.5 ng/mL (1.8-19.9 ng/mL), a known feature of lipodystrophy. However, triglycerides are only 158 mg/dL (&lt;150 mg/dL), which may point more toward isolated leptin deficiency without lipodystrophy.
Modified insulin challenge was administered in office to differentiate between true insulin resistance and poor compliance. Insulin lispro 0.3 units per kilogram subcutaneous (14 units total) was administered at time zero, with pre-test SMBG 575 mg/dL. Over the three-hour test, blood sugars reached a nadir of 297 mg/dL. Patient was observed throughout and did not eat or drink anything but water during the test. He showed no signs or symptoms of hypoglycemia at any time during the challenge. Results indicated significant insulin resistance for his body weight.

Conclusion
Physical exam features, labs, including leptin of 0.5 ng/mL, and relatively severe insulin resistance suggest possible lipodystrophy or isolated leptin deficiency. However, triglycerides were not extremely elevated as expected in lipodystrophy. We have ordered metreleptin for further elucidation of patient's condition.
Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN143 Perspectives of Patients Attending Endocrinology Clinic About COVID-19 Vaccination.
Authors: Mikkilineni Pushyami , Simon Rebecca , Bhan Arti , Rao Sudhaker D 
Published: November 2022

Abstract

Introduction
The outbreak of coronavirus disease 2019 (COVID-19) was initially detected in Wuhan, China in December 2019. It spread rapidly, and in March 2020, the World Health Organization (WHO) declared a worldwide pandemic. In May 2020, the 73rd World Health Assembly issued a resolution recognizing the role of extensive immunization as a global public-health goal for preventing and stopping transmission of COVID-19. Vaccine hesitancy is a great threat in fighting the COVID-19 pandemic, as it prevents populations from reaching target thresholds of coverage necessary for herd immunity. It is important to know the determinants of vaccine hesitancy so that we can develop tools to combat it. The goal of our study was to evaluate patient perspectives on vaccination in our outpatient Endocrinology clinics.

Methods
We created a 7-question survey study which was offered to all patients waiting to be seen in our three Endocrinology clinic locations. We distributed and collected data from all clinics over a 3-week period (5/31/21-6/18/21). We used descriptive statistics to analyze this data.

Results
We collected 446 responses between three clinic locations, one urban and two suburban. 361 patients (81%) reported planning to or already having received the COVID-19 vaccine. 29 patients (7%) reported being unsure and 56 patients (13%) reported they did not plan to get vaccinated. Among 85 patients with vaccine hesitancy, 51% are blacks, 35% are whites, 24% reported concerns related to side effects, 13% felt COVID was not as bad as the media portrays, 14% did not believe in vaccines and 29% wanted more data on side effects and efficacy before receiving it. Hesitancy is higher among blacks which is statistically significant (P = 0.035) and slightly higher at the urban compared to the suburban clinics (20% Vs. 15%; p=0.197). On chi square analysis, this had no significant difference.

Discussion
In the United States, COVID-19 vaccine acceptance ranged from 60 to 79% in five surveys among the general population. The rate of vaccination acceptance is higher in our study compared to general population. We suspect this is related to our clinic patients having better vaccine counseling as most patients have multiple risk factors for severe infection. The results did show higher vaccine hesitancy among black patients and those seen in our urban clinics suggesting the need for improvement in health literacy in these populations.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN158 INTENSIVE VS. CONVENTIONAL BLOOD PRESSURE GOALS IN OLDER PATIENTS WITH TYPE 2 DIABETES: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Rodriguez-Gutierrez Rene , Rodriguez Andrea Flores , Raygoza-Cortez Karina , Garcia-Leal Mariana , Mariño-Velasco Sofia , Plata-Huerta Hiram H , Sãenz-Flores Melissa , Ramirez-Garcia Luz A , Rojo-Garza Amanda , Colmenero Fernando Diaz-Gonzalez , Maraka Spyridoula , Singh-Ospina Naikky V , Brito Juan P , Gonzãlez-Gonzãlez Jose G 
Published: November 2022

Abstract

Background
Hypertension is a major cardiovascular risk factor that affects over 50% of individuals with type 2 diabetes. Lowering blood pressure to reduce the risk of micro- and macrovascular complications of diabetes is a strong recommendation advocated by contemporary clinical practice guidelines, however, proposed goals for older patients with diabetes are heterogeneous and rely on indirect evidence as they are frequently underrepresented in clinical trials. Herein, the optimal blood pressure goal and its associated risks remain uncertain in this population.

Objective
To assess the effect of intensive vs conventional blood pressure goals on patient important outcomes in older adults with type 2 diabetes.

Methods
A comprehensive search was performed using MEDLINE, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled trials, and Cochrane Database of Systematic Reviews, from database inception to March 2021. Randomized controlled trials comparing intensive vs conventional blood pressure goals in adults over 60 years of age with type 2 diabetes were included. Screening and data extraction were performed independently and in duplicate. Modified Mantel-Haenszel meta-analyses were conducted to estimate odds ratios (OR) for dichotomous outcomes and mean differences for continuous outcomes, alongside 95% confidence intervals (CIs). (PROSPERO registration number: CRD42019126078)

Results
Seven trials fulfilled our inclusion criteria.A 19% risk reduction (OR 0.81; 95% CI 0.69 to 0.95; I2= 8%; p= 0.35) in the occurrence of major adverse cardiovascular events (MACE) and 37% risk reduction (OR 0.63; 95% CI 0.51 to 0.79; I2= 0%; p= 0.56) in the occurrence of fatal or non-fatal stroke was documented in the intensive treatment group. There were no differences in the occurrence of all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction, and peripheral vascular disease. Data regarding treatment adverse effects and microvascular outcomes were scarcely reported among included studies.

Conclusion
In summary, our analysis provides evidence that intensive blood pressure goals in older patients with diabetes are associated with a lower risk of stroke and MACE. Nevertheless, data are very scarce regarding microvascular diabetes outcomes and treatment safety. Given that an intensive approach would increase the number of medications, cost, adverse events and probably decrease adherence, treatment of hypertension in this population should be conducted with a shared decision making approach that makes sense from an intellectual, emotional, and practical basis.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN169 Vitamin C Renal Leak in Diabetes
Authors: Ebenuwa Ifechukwude , Violet Pierre-Christian , Tu Hongbin , Wilkins Kenneth , Levine Mark 
Published: November 2022

Abstract

Background
People with diabetes have lower plasma vitamin C concentrations compared to nondiabetic individuals. The prevalence of urinary vitamin C loss, and its relationship to plasma vitamin C concentrations are unknown.

Methods
In this cross-sectional cohort study of 162 individuals; 82 with diabetes and 80 nondiabetic controls, we investigated the prevalence and clinical characteristics of vitamin C renal leak, using fasting plasma and matched 1h urine samples. Based on vitamin C renal threshold, vitamin C renal leak was defined as presence of vitamin C in urine with plasma concentrations less than the minimal elimination threshold (MET) of 43.2µM in women or 38.1µM in men. We also assessed group differences in mean plasma vitamin C concentrations and investigated the association between diabetes-related clinical variables and renal leak. Vitamin C in plasma and urine was measured using coulometric electrochemical detection with high performance liquid chromatography.

Results
When compared with nondiabetic controls, subjects with diabetes had significantly increased prevalence of vitamin C renal leak (8.8% vs 32.9%: OR5, p&lt;0.001) and decreased plasma vitamin C concentrations (53.1µM vs 40.9µM, p&lt;0.001). Higher fasting plasma glucose, glycosylated hemoglobin A1c, body mass index, micro/macro vascular complications and protein creatinine ratio were predictive of vitamin C renal leak.

Conclusion
Increased prevalence of vitamin C renal leak in diabetes is associated with reduced plasma vitamin C concentrations. Glycemic control, microvascular complications, obesity, and proteinuria were associated with renal leak.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.