bluuebunny/crossref_metadata_2025_split huggingface dataset:
PSUN259 A Severe Case of Fournier's Gangrene Associated With Dapagliflozin
Authors: Syed Shumail , Sindi Ghassan , Zena Mohsen 
Published: November 2022

Abstract

Background
SGLT2 inhibitors have gained popularity in treatment of Type 2 Diabetes, and recently in lowering the risk of major adverse cardiovascular events (MACE). Genitourinary infections are well known side effects of SGLT2 inhibitors. Fournier's gangrene is a necrotizing fasciitis of the perineum which can be rarely associated with SGLT2 inhibitors. Between 2013 to 2018, the FDA received 12 case reports of Fournier's gangrene in patients taking SGLT2 inhibitors. Glucosuria from the medication creates a milieu which increases the chances of developing Fournier's gangrene. The annual incidence of Fournier's gangrene in the general population is 1.6/100,000 males in the US. Here, we present a case of Fournier's gangrene within few months of starting Dapagliflozin.

Clinical case
A 62-year-old male with history of poorly controlled Type 2 DM was brought to the ED after being found down at his residence covered in feces. He reportedly had nausea, vomiting and diarrhea for 3 days prior to his presentation. His diabetes home regimen consisted of metformin 1000 mg BID, oral semaglutide 14 mg daily, glimepiride 8 mg daily, pioglitazone 45 mg daily and dapagliflozin 10 mg daily. Of note, dapagliflozin was started 3.5 months prior to presentation. Workup revealed WBC count 14.2 k/ul with left shift, sodium 132 mmol/L, HCO3 15 mmol/L, anion gap 26 mmol/L, glucose 432 mg/dL, Cr 3.27 mg/dL (Baseline 1.18 mg/dL), Lactic acid 2.7 mmol/L, AST 131 u/l, CK 905 u/l and A1c 9.2%. CT abdomen and pelvis with contrast showed necrotizing infection of the scrotum and perineum, consistent with Fournier's gangrene. Gas was seen tracking into the mesorectal fascia layer in the extraperitoneal spaces of the pelvis. He was given IV antibiotics and IV fluids per sepsis protocol. Urology and General Surgery consultations were obtained with the patient taken emergently to the operating room and underwent exploration of groin with debridement of genitals, right gluteal and perianal debridement, and bilateral orchiectomy. The patient had an extensive hospital stay with gradual improvement in clinical status. He later underwent extensive reconstructive plastic surgery. All oral diabetes medications were discontinued, and he was ultimately discharged on an insulin regimen consisting of insulin glargine 20 units BID, insulin lispro 5 units before meals and insulin lispro correction scale.

Conclusion
SGLT2 inhibitors remain valuable drugs in treating Type 2 Diabetes. Fournier's gangrene is a rare but serious possible adverse effect of SGLT2 inhibitors that requires a high index of suspicion to recognize. Time to onset of Fournier's gangrene after initiation of SGLT2 inhibitor therapy can be variable. Patients on SGLT2 inhibitors should be alerted to seek medical attention if they develop fever associated with pain, redness, or swelling in the genital or perineal area.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN272 Opportunity for Inpatient Use of Continuous Glucose Monitoring: A Case Report of Acute Pancreatitis Secondary to Hypertriglyceridemia
Authors: Romo Karina G , Regennitter Nicholas S , Martinez-Vargas Valerie , Karam Susan 
Published: November 2022

Abstract

Background
Continuous glucose monitoring (CGM) is a convenient method of estimating blood glucose (BG) levels through a minimally invasive subcutaneous electrode that senses interstitial fluid glucose readings. With recent advancements, this technology has the potential to transmit interstitial fluid glucose readings to electronic health records (EHR) in real-time. While some benefits of CGM have been studied in outpatient settings, current CGM research is beginning to explore the use and benefits of CGM in inpatient settings. The following case of acute pancreatitis (AP) secondary to hypertriglyceridemia (HTG) presents a novel opportunity for inpatient use of CGM.

Clinical Case
A 33-year-old-man with anxiety, alcohol use disorder, and without insulin resistance, presents as a transfer to a tertiary-care-center for consideration of plasmapheresis in the setting of AP secondary to HTG. He initially presented to outside hospital with acute onset diffuse abdominal pain. Family history of father with controlled HTG and hyperlipidemia on statins. Hemodynamically stable. Examination revealed diffuse abdominal tenderness. Labs revealed triglyceride (TG) level 3550 mg/dL (n&lt;150 mg/dL), lipase 1423 U/L (n 0-160 U/L), TSH normal, A1c 5.2% (n&lt;5.7%). CT abdomen pelvis with contrast revealed moderate acute interstitial edematous pancreatitis without necrosis, pseudocyst, or mass. He was volume resuscitated with intravenous (IV) fluids, then started on a non-titratable regular insulin infusion (N-TII) at 2 U/hr and continuous IV fluids with dextrose. Upon arrival, his BG was 101 mg/dL. The N-TII rate was decreased to 1 U/hr and managed with hourly finger-stick BG checks and continuous IV fluids with dextrose plus KCl. Arrival TG was 954 mg/dL. The case was discussed with Transfusion Medicine—given the down-trending TG level, plasmapheresis was not initiated. The next morning, repeat TG level was &lt;500 mg/dL, thus, the N-TII was discontinued. During admission, BG ranged from 86-179 mg/dL and IV fluids with dextrose required titration of rate and concentration to avoid hypoglycemia while severe HTG resolved.

Conclusion
This case presents a novel scenario in which there is an opportunity for inpatient use of CGM. In addition to point-of-care finger-stick BG checks, the implementation of inpatient CGM may be beneficial in tracking glucose trends when N-TII are required for management of severe HTG, but risk iatrogenic hypoglycemia. Not only does this highlight an area in need of further research and technological developments that link CGM data to EHR in real-time, but also, by continuing to identify new opportunities for inpatient CGM use, we can better understand its nuances and implications, thus, thoughtfully advocate for policies and protocols that optimize benefits and justify cost of inpatient CGM.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN276 GLP1RAs use for treating NALFD in a multidisciplinary clinic in low socioeconomic community
Authors: West Brittany , Mon Sann , Myint Alex , Lees Heather 
Published: November 2022

Abstract

GLP1RAs have been proven beneficial for weight loss in patients with NAFLD with or without Diabetes. However, such use is limited due to cost and limited insurance coverage in those without diabetes.
Method: Retrospective chart review of patients with NAFLD seen at Multidisciplinary NAFLD clinic in Low SES community
Result: A total of 11 patients (55% Female, mean age 49.2±13.8 yrs, BMI 39.3±7.8 kg/m2) diagnosed with NAFLD were seen by hepatologist, endocrinologist and dietician and instructed and counseled for lifestyle modification aiming for at least 5% weight loss within 6 months. Five had diabetes with A1C 6.7% to 8.3%, and the remaining had Pre-Diabetes. Semaglutide 1 mg weekly SC was used in 8 patients (72.3%), liraglutide 3 mg qd in 1 patient, metformin in 1 patient, generic phentermine topiramate in 1 patient. Initial data of SBP(mean 129±9.0 mmHg), LDL (mean 97.8±31.6 mmol/L), TAGs (mean 193.6±109.6 mg/dl), AST (mean 43.5±21.8 U/L), and ALT (mean 50.8±25.9 U/L) were collected and followed at 6 and 12 months. Among 8 patients with complete 1 year data, all except one (87.5%) achieved weight loss goal at least 5% at 6 and 12 months. Among Five patients with greatest weight lost 14-20% at 1 year with significant improvement in metabolic panels, 80% of them were on GLP1RA. At 6 months and 12 months mean SBP was 125.3±5.8 and 123.9±10.3 mmHg, mean LDL was 75.5±16.4 and 71.4±21.2 mmol/L, mean TAGs was 161.2±114.5 and 158.7±90.9 mg/dl, mean AST was 19.4±4.0 and 19.4±4.5 U/l, and mean ALT was 26.7±8.3 and 33±16.1 U/L respectively.

Conclusion
In this case series from our multidisciplinary NAFLD clinic, we observed the achievement of weight loss goal and improved clinical parameters by 12 months. The clinic can be beneficial in low SES community.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN277 Symptomatic Hypoglycemia Associated with Over The Counter Supplement
Authors: Izkhakov Neriy , Zweibach Eugenia , Vernetti Nicholas , Nakhle Samer 
Published: November 2022

Abstract

Background
Insulin autoimmune syndrome (IAS), first described in 1970 in Japan, is characterized by spontaneous fasting or postprandial hypoglycemia with evidence of elevated serum insulin levels and anti-insulin antibodies in individuals with no prior exposure to exogenous insulin. IAS has been mostly reported in Asia. Genetically susceptible individuals, with HLA-DR4, are reported to have higher incidence of IAS. Possible triggers include Sulfyhdryl group containing compounds.

Clinical Case
We report a case of a 25-year-old female of asian descent (133lbs, BMI 22.3 kg/m2) with no significant medical or surgical history, who was referred for an evaluation of hypoglycemia. She did not have diabetes mellitus and never administered insulin or sulfonylureas. Patient started a glutathione supplement for skin care and six months later she switched to glutathione-blend supplement (total daily intake Glutamic Acid 360 mg, Glycine 400mg, L-Cysteine 240mg, NAC 200 mg, Vitamin C 200mg, Alpha Lipoic Acid 100mg, Grapeseed Extract 50mg). Patient reported being asymptomatic for the initial 3 months of taking the new glutathione blend supplement. At that time she developed symptoms of dizziness, diaphoresis, palpitations, muscle weakness, headaches and sugar craving. She reported that these symptoms resolved with administration of glucose and recurred every 2-3 hours after meals and overnight. Baseline continuous glucose monitor (CGM) data showed average glucose of 74 mg/dL, 60% in target range (70-180mg/dL), 38% Low glucose levels (54-69 mg/dL), and 2% very low (&lt;54 mg/dL) Her baseline labs while on glutathione blend supplement showed serum glucose 71 mg/dL, insulin 815 uIU/mL (UNL 25 uIU/mL), proinsulin 18.6 pmol/L (UNL 10 pmol/L), c-peptide 4.2 ng/mL (UNL 4.4 ng/mL), insulin antibodies &gt; 625 uU/mL (&lt;5 uU/mL negative). A week after supplement discontinuation, patient's symptoms have improved with reduction in frequency of hypoglycemia. Serum markers were repeated on 3 separate occasions (at 2 weeks, 3 months, and 5 months off supplement). All markers of insulin production were progressively decreasing. Insulin antibodies remained above the upper limit of the detection. By five months off supplement, she was able to fast for 6 hours without episodes of hypoglycemia. At that time her labs showed serum fasting glucose 83 mg/dL, insulin 286 uIU/mL, proinsulin 6.7 pmol/L, c-peptide 3.3 ng/mL, insulin antibodies &gt; 625 uU/mL. CGM data at five months off supplement showed average glucose of 95 mg/dL, 100% in target range.

Conclusion
This is a rare case of supplement induced insulin autoimmune syndrome due to which the patient developed profound hypoglycemia. This case illustrates that once the supplement (alpha lipoic acid and glutathione) is discontinued there is an improvement in clinical and laboratory markers of hypoglycemia.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN281 Safety and Efficacy of Virtual Insulin Pump Initiation in Adults with Diabetes
Authors: Everett Estelle , Freeby Matthew , Gaffny Kailee , Educator Certified Diabetes 
Published: November 2022

Abstract

Background
Insulin pump therapy is an integral part of diabetes management. The COVID-19 pandemic posed challenges to the usual insulin pump initiation process, prompting an increased reliance on virtual training, but the effectiveness and safety of this approach is unclear.

Methods
In an academic urban diabetes clinic, we examined insulin pump initiations in 30 sequential patients who underwent virtual training between May 2020 and February 2021 and in 15 patients who received in-person training between October 2018 and April 2020. Patients met with a diabetes educator for 4 sessions either remotely in the virtual group, or in-person in the routine care group. All patients used a continuous glucose monitor (CGM) prior to insulin pump training. We compared glycemic control using the following CGM metrics at baseline and 6 months: percentage time in range (70-180mg/dL), hypoglycemia (BG &lt;70), and hyperglycemia (BG &gt;180). We calculated the time interval between decision to start and the day of insulin pump initiation (lead time). We used descriptive statistics to report baseline characteristics of patients. We plotted each measure and used Shapiro-Wilk Test to determine the distribution of each outcome. As these measures were non-normally distributed, we used medians and interquartile ranges to describe glycemic outcomes and Wilcoxon signed rank test to assess statistical differences between the groups.

Results
Overall both patient groups were predominantly white (77.8%), non-Hispanic (86.6%), male (60.0%), and with type 1 diabetes (80%); the average age was 43 years. Baseline time in range was 61.0% (IQR 34.0%, 78.4%) and 65.8% (IQR 35.0%, 78.0%) in the virtual and routine groups, and 70.9% (IQR 52.2%, 83.0%) and 65.0% (IQR 48.8%, 88.9%) at 6 months. Baseline time in hypoglycemia was 0.4% (IQR 0%, 1.6%) and 0.5% (IQR 0.1%, 2.0%) in virtual and routine groups, and 0.8% (IQR 0.2%, 1.75%) and 0.3% (IQR 0%, 1.0%) at 6 months. Baseline time in hyperglycemia was 40.0% (IQR 20.3%, 66.0%) and 34.1% (IQR 13.0%, 65.0%) in the virtual and routine groups, and 25.0% (IQR 16.9%, 43.0%) and 35.0% (IQR 11.1%, 50.9%) at 6 months. There was no statistically significant difference in glycemic outcomes between the groups at baseline or at 6 months. One case of diabetic ketoacidosis occurred in both groups after pump initiation; there were no hospitalizations in either group. The lead time for virtual group training was 45 days (IQR 35, 60), significantly shorter than routine care at 80 days (IQR 50, 123; p=0.026).

Conclusion
Our study demonstrates timely initiation of pump therapy via virtual training without increased rates of hypo- or hyperglycemia. The data suggest virtual insulin pump training can be effective, efficient, and safe. Larger studies are needed to confirm these findings.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN30 Circulating EVs from patients with SDHB mutations increase HIF signaling in hPheo1 cells
Authors: Ghayee Hans , Bala Niharika , Liu Lauren , Xu Yiling , Cusi Kenneth , Pacak Karel , Alli Abdel 
Published: November 2022

Abstract
Extracellular vesicles (EVs) are nanosized vesicles that carry bioactive cargo from one cell to another and play an important role in intracellular signaling, cell differentiation, and intercellular communication. We investigated and found that packaged cargo of circulating EVs from SDHB mutated pheochromocytoma/paraganglioma patients increase hypoxia-inducible factor (HIF) signaling in a cell model system compared to EVs from control subjects. Keywords: Adrenal Tumors, Endocrine Neoplasia, Neuroendocrinology, succinate dehydrogenase
Presentation: Saturday, June 11, 2022 1:00 p.m. - 2:00 p.m.
RF04 | PSUN295 Evolution of Monomeric Multi-Agonists of GLP-1 and NPY Receptors
Authors: Chichura Kylie , Elfers Clinton , Salameh Therese , Sweet Ian , Roth Christian , Doyle Prof Robert 
Published: November 2022

Abstract
Current treatments for type 2 diabetes (T2D) and obesity do not reliably achieve long-term weight-loss and up to 50% of patients experience nausea and vomiting. Thus, there is a critical need for obesity medications that provide glycemic control with enhanced hypophagic response without nausea/emesis. Based on rational design and in silico modelling of the glucagon-like peptide 1-receptor agonist (GLP1RA) exendin-4 (Ex4) and the neuropeptide Y2 receptor (Y2R) agonist peptide YY (PYY) 3-36, we have developed and screeened several new monomeric chimeric peptides that display dual agonism of the anorectic Y2R and the glucoregulatory GLP1R. In addition, we explored a third agonistic behavior at the neuropeptide Y1 receptor (Y1R), which potentially relates to pancreatic beta-cell protection. Our current lead, GEP44, binds the Y2R, Y1R, and GLP1R. We tested effects of daily injections of these chimeric peptides in adult Sprague-Dawley rats on food intake (FI), body weight (BW) changes, blood glucose levels and an indicator of nausea (kaolin intake). GEP44 produced profound reduction in FI (2-d average GEP44 at 20 nmol/kg FI -71%; Ex-4 20 nmol/kg FI -40%). Anorectic doses of GEP44 did not trigger a pica response assessed by kaolin consumption in treated rats, while in Ex-4 treated rats, kaolin consumption accounted for 28% of total daily solid intake, indicating a clear nausea response. In addition, we assayed for emetic response in the musk shrew, with little to no such emesis displayed (n=8) for GEP44 (1/8), but emesis noted across all animals tested for Ex4. During 11 d of treatment with GEP44, FI was consistently reduced resulting in a significantly stronger reduction of BW compared to Ex4 at the end of treatment (GEP44 -7.6%, Ex4 -3.7%, p&lt;0.05). Furthermore, 5-day injections of GEP44 showed greater reduction of glucose levels than for Ex4 in diet induced obese rats receiving ip glucose. In conclusion, simultaneously targeting serial anorectic pathways with single molecule chimeric peptides can address multiple coexisting conditions to more efficaciously reduce FI, BW and blood glucose levels, devoid of side-effects to improve patient patient and quality of life.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 1:05 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
RF16 | PSUN335 Clinical Effects of Sodium Glucose Transporter Type 2 Inhibitors in Patients with Severe Insulin Resistance
Authors: Bansal Rashika , Brown Rebecca , Cochran Elaine , Startzell Megan 
Published: November 2022

Abstract

Background
Severe insulin resistance syndromes including lipodystrophy and pathogenic variants in the insulin receptor (INSR) lead to diabetes that is challenging to control. Oral antidiabetic agents have been used to control hyperglycemia, however the efficacy of these treatments has not been studied systematically. This study explores safety and efficacy of sodium glucose cotransporter 2 inhibitors (SGLT2i) in these patients.

Methods
This was a retrospective chart-review assessing safety (N=31) and efficacy (N=18) of SGLT2i use in patients with clinically or genetically confirmed diagnosis of lipodystrophy or INSR pathogenic variants at our institute. Efficacy outcomes included HbA1c, insulin dose, C-peptide, fasting insulin and 24-hour urine glucose at 12 months and throughout follow-up from 2 to 24 months. Glycemic parameters were analyzed as change from baseline (prior to SGLT2i) adjusted for baseline values after 12 months of SGLT2i and across all timepoints using linear mixed models with post-hoc Dunnett-adjusted comparison of each time point compared to baseline. For HbA1c, additional models were conducted including change in insulin dose as a covariate.

Results
HbA1c did not significantly change after 1 year of SGLT2i (baseline 9.5±2.5 [80.3±27.7]; 12 months 8.8±2.3% [72.6±25.3 mmol/mol]; p=0.093), or across all time points (p=0.11). However, most patients (83%) were taking insulin, and SGLT2i treatment led to 35% reduction in total daily dose of insulin after 12 months (baseline 186 [100,1010]; 12 months 120 [75,260] units/day; p=0.07) and across all visits (p=0.035), which may have mitigated the reduction in HbA1c. Reduction in HbA1c was significant after adjustment for changes in insulin dose over time (p=0.0498). No significant change was noted in C-peptide, however fasting insulin decreased after 12 months (p=0.021) and across all visits (p=0.005). Urinary glucose excretion increased greater than 5-fold after 12 months of SGLT2i, to over 80 grams per day after 1 year (p=0.04). Adverse effects occurring in &gt;1 subject included hypoglycemia, fungal infections, and extremity pain.

Conclusions
SGLT2i reduced insulin dose, insulinemia, and insulin dose-adjusted HbA1c in patients with severe insulin resistance, with a similar safety profile compared to type 2 diabetes. SGLT2i use may lead to overall better glycemic control and should be considered as part of the treatment armamentarium for these rare forms of diabetes, but larger trials are needed to confirm these findings.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:36 p.m. - 12:41 p.m.
RF28 | PSUN184 New American Diabetes Association Definition of Diabetes Remission Does not Correlate with Time in Remission in Ketosis-Prone Diabetes
Authors: Oladejo Omolade , Rashied Ammar , Umpierrez Guillermo , Vellanki Priyathama 
Published: November 2022

Abstract

Introduction
Approximately 50% of obese Black patients presenting with diabetic ketoacidosis (DKA) at new-onset of diabetes have immunologic and metabolic features of type 2 diabetes, also called ketosis-prone diabetes (KPDM). With intensive insulin treatment, ∼70% have improvements in beta-cell function and insulin sensitivity and achieve diabetes remission. The definition of remission in KPDM has been heterogeneous with our group defining remission as HbA1c &lt; 7%, fasting blood glucose (BG) &lt; 130 mg/dl and random BG &lt; 180 mg/dl while off insulin injections for at least 1 week. In 2021, the American Diabetes Association (ADA) consensus recommended that the definition of diabetes remission as HbA1c &lt; 6.5% or a fasting BG &lt; 126 mg/dl while off medications for &gt; 3 months. We hypothesized that patients who achieved the more intensive ADA definition of remission (HbA1c &lt; 6.5%) will have longer time in remission compared to our previous non-intensive definition of remission (HbA1c 6.5-7%).

Methods
Forty obese Black patients (BMI ≥ 28 kg/m2) with newly diagnosed diabetes and unprovoked DKA had intensive insulin therapy until HbA1c &lt; 7% without insulin therapy for at least one week. Patients were followed until hyperglycemia relapse (HbA1c &gt; 6.5% or fasting BG &gt; 126 mg/dl and/or requiring antidiabetic medications). Baseline characteristics and clinical time to hyperglycemia relapse-free survival were compared between patients with HbA1c &lt; 6.5 (n= 24) and HbA1c 6.5-7% (n=16).

Results
Age, sex, family history of type 2 diabetes, BMI, HbA1C, weight change and insulin doses received between the two groups (HbA1c &lt; 6.5 vs 6.5-7%) did not differ significantly. Median follow-up overall was 404 days with a range of 7-1099 days. In patients that experienced a hyperglycemia relapse, bivariate analysis shows that median days to hyperglycemia relapse was longer in HbA1c &lt; 6.5% (411 days, range (17-804) vs HbA1c 6.5-7% (126 days, range (7-391), p= 0.05) but without a statistical difference. Survival analysis showed that time in remission did not statistically differ between the two groups (log rank, p=0.6853).

Conclusion
In obese Black patients with KPDM, HbA1c &lt; 6.5% at time of insulin discontinuation does not prolong diabetes compared to patients that achieved HbA1c 6.5-7%, suggesting that predictors of prolonged remission may differ among diverse populations with diabetes.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:44 p.m. - 12:49 p.m.