bluuebunny/crossref_metadata_2025_split huggingface dataset:
PSUN370 Refractory Hypoglycemia Associated with a Metastatic Neuroendocrine Tumor Producing Multiple Hormones
Authors: Colon-Barreto Brigida , Liu Zhao , Steinberg Helmut , Karki Kanchan 
Published: November 2022

Abstract

Introduction
Neuroendocrine tumors are rare. They are derived from hormone-producing and nerve cells mostly found in GI tract, lung or pancreas. In about half of the cases, work-up does not detect any tumor-related hormone secretion. Even less common, the tumor produces several hormones which may be associated with clinical symptoms.

Clinical Case
A frail 81-year-old male with mild-to-moderate dementia and no history of diabetes presented to the emergency department with complaints of generalized weakness, fatigue, weight loss, poor appetite, diarrhea and shortness of breath for 1-2 weeks. Physical examination was pertinent for cachexia, general pallor, dry oral mucosa and having heme positive stool. Initial laboratory work-up found anemia (Hg 5.8g/dl), low glucose of 43 mg/dL, hypoalbuminemia (Alb 1.9 gm/dL). CT angiogram of abdomen did not show any active bleed but showed incidental diffuse hepatic lesions favoring metastatic disease, pancreatic ductal dilatation and fluid-filled loops of small and large bowel compatible with enteritis. Subsequent endoscopy and colonoscopy were negative for malignancy. Findings of multiple liver lesions prompted a CT-guided liver biopsy which showed a metastatic, well differentiated neuroendocrine tumor WHO grade II/III with positive stains for chromogranin A, synaptophysin, cytokeratin Oscar (Ki-67 less than 20%). MRCP abdomen examination of pancreas showed no focal pancreatic lesions but was suboptimal due to motion artefacts and lack of contrast. Workup for the tumor revealed increased serum serotonin (772 ng/ml), increased 5-HIAA (3,175 ng/ml), increased chromogranin A (48,436 ng/ml) and an increased 24hr Urine 5-HIAA (162mg/24hr). Further workup for the persistent and hypoglycemia showed a random cortisol 24.6mcg/dl. During hypoglycemia, insulin and C-peptide levels were 4.3 uU/L and 1.4ng/ml indicating inappropriately "normal" insulin production consistent with an insulinoma. IGF 1 and IGF 2 levels were withing the normal range.
The hypoglycemia was initially managed with continuous intravenous administration of dextrose and optimization of oral intake, glucagon and octreotide 50 mcg every 8 hours. However, the response to octreotide was insufficient and we were unable to wean the patient off the dextrose. Subsequently we started prednisone 20 mg oral daily and glucose tablets which allowed us to discontinue the intravenous dextrose and the octreotide. Patient was discharged home on hospice care.

Conclusion
Hypoglycemia is a potentially life-threatening condition necessitating prompt action including the administration of intravenous dextrose. The results of the workup indicate that the neuroendocrine tumor produced excessive amounts of both serotonin and insulin contributing to prolonged refractory hypoglycemia. Treatment of this rare condition is challenging and often empirical.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN240 A Case of Euglycemic DKA in Pregnancy
Authors: Grigoryan Seda , Oral Elif 
Published: November 2022

Abstract

Background
Euglycemic diabetic ketoacidosis (EKDA) is a rare diagnosis of exclusion occurring in a state of decreased hepatic production of glucose due to fasting state or enhanced urinary excretion of glucose. Pregnancy predisposes a woman to a state of accelerated starvation, where even short periods of fasting can lead to increased lipolysis and subsequent ketosis. DKA can develop quickly at lower serum glucose concentrations when triggers such as stress, pump malfunction, infection are present. EDKA is particularly important to recognize and treat in pregnant patients, as this increases risk of fetal demise. Diagnostic criteria of EKDA are elevated beta-hydroxybutyrate in serum or urine, decreased serum bicarbonate, glucose &gt; 200 mg/dL, anion gap metabolic acidosis.Clinical case:26-year-old female G1P2 at 29-weeks’ gestation, with a medical history of type 1 diabetes mellitus on insulin pump, hypothyroidism, prior pregnancy complicated by pre-eclampsia presented as a transfer from an outside hospital after a low-impact motor vehicular accident. Patient was transferred with concern for DKA. At the time of presentation patient had been using her insulin pump per home settings, was NPO for at least 24 hours due to nausea and mild abdominal pain. BP was 140/77 mmHg, HR 114 beats/min, 97.6F, RR 16 with SpO2 99% on RA. Patient was alert and oriented, not in acute distress. Labs were notable for beta-hydroxybutyrate of 3.3 mmol/L, lactate 1.0 mmol/L, HbA1c 7.3%, TSH 3.16 mIU/L, Na 136 mmol/L, K 4 mmol/L, Cl 105 mmol/L, serum bicarbonate 18 mmol/L, glucose 97 mg/dL, creatinine 0.49 mg/dL, eGFR &gt;90 mL/min/1.73m2, anion gap of 13 mmol/L. Patient was found to be in euglycemic DKA and was started on IV insulin with fluid resuscitation per protocol. Endocrinology was consulted as labs demonstrated worsening, with Na 135 mmol/L, serum bicarbonate 17 mmol/L, glucose 166 mg/dL. At this point patient had just started tolerating PO intake, no fetal distress was observed. We recommended continuation of treatment for a total of 24 hours, with subsequent normalization of labs and resolution of nausea. Patient was transitioned to home insulin pump with recommendation to snack frequently between meals and was discharged home with outpatient follow up. Upon follow up, patient did not experience recurrence of DKA but had been induced at 33 weeks due to pre-eclampsia, successfully giving birth to a live baby girl with Apgar scores of 5/6.

Conclusions
EDKA is a rare but easily missed diagnosis that is important to treat particularly in a pregnant patient, as risks of fetal demise are high. Serum or urine ketones should be checked in any hospitalized diabetic patient regardless of symptoms or other laboratory indicators. Triggers of EKDA in a state of pregnancy can include brief periods of fasting, infection, stress, and dehydration.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN260 Diabetic Myconecrosis: a Rare Complication of Uncontrolled Diabetes Mellitus
Authors: Joseph Marina , Ram Roopa , Ambrogini Elena 
Published: November 2022

Abstract

Introduction
Spontaneous diabetic myonecrosis is a rare and underdiagnosed microvascular complication of long standing and poorly controlled diabetes mellitus. The pathogenesis of this infarction of the skeletal muscle appears to be related to vasculopathic changes without an atheroembolic event or occlusion of major arteries. The factors responsible for the acute onset of symptoms are unknown. Since the initial description in 1965, only 170 cases have been described, including 126 initial episodes and 44 episodes of recurrence, with a mean age at presentation of 45 years (range 20 to 67 years). Most of the patients have other microvascular complications. Characteristic symptoms at presentation include acute onset unilateral lower limb pain and swelling, most often in the thigh, without a history of trauma. Bilateral involvement is present in approximately 30% of the cases. Fever has been reported only in about 10% of cases.

Case Report
A 23-year-old female presented with ten days history of fever, left groin pain and inability to walk. Other than chronic fatigue, her review of symptoms was mostly negative. She denied any trauma. She had a history of poorly controlled type 1 diabetes mellitus (HbA1c 10.5%) with diabetic nephropathy (proteinuria),but no evidence of retinopathy or neuropathy. On examination, her left groin and proximal thigh were warm and tender to palpation without noticeable erythema or swelling. Labs showed elevated inflammatory markers. CT scan showed inguinal and retroperitoneal lymphadenopathy with subcutaneous edema of the visualized left lower extremity. Fevers persisted despite appropriate administration of antibiotics for cellulitis. Infectious workup was negative. A biopsy of her inguinal lymph node showed reactive changes. MRI of her left thigh showed large, confluent areas of intramuscular hypo enhancement compatible with diabetic myonecrosis. Her symptoms improved over the next 3-4 weeks with supportive care.

Discussion
Spontaneous diabetic myonecrosis is a very rare complication of uncontrolled diabetes. Knowledge about his condition is required to make the correct diagnosis and avoid the use of unnecessary laboratory tests and treatments. The presence of the characteristic clinical features such as pain and swelling in typically affected areas such as the thigh, will frequently suggest the diagnosis. MRI with intravenous contrast enhancement is the diagnostic imaging of choice and shows increased signal on T2-weighted images from muscle edema and areas of non-enhancement from myonecrosis. Treatment involves symptomatic management with rest, optimal glycemic control, analgesia, and low-dose aspirin, although the optimal treatment approach is uncertain. The short-term prognosis is good, but the recurrence rate remains high and long-term prognosis is poor given underlying poorly controlled diabetes.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN285 Use of Continuous Glucose Monitoring in Managing Neonatal Diabetes in a Very Low Birth Weight Infant with a GATA-6 Mutation
Authors: Halpin Kelsee , Metzinger Emily 
Published: November 2022

Abstract

Introduction
Although continuous glucose monitoring (CGM) has increased in patients with Type 1 diabetes, its use in the neonatal population has remained limited. Neonates, particularly preterm infants, are at risk of impaired glucose control. Several studies have looked at the use of these devices in improving care for premature infants without diabetes. We describe a case of a very low birth infant with neonatal diabetes secondary to a GATA-6 mutation.

Clinical Case
This is a late preterm infant with IUGR, truncus arteriosus, and neonatal diabetes. Exome genetic panel showed a mutation in GATA-6. Her neonatal diabetes was challenging to control due to variable blood sugars and sensitivity to insulin. Weight gain remained poor. A CGM (Dexcom G6) was placed when the infant was 1.59kg to optimize her diabetes management and improve weight gain. An insulin titration chart was used to adjust her IV regular insulin infusion according to the CGM glucose levels and trend arrows. The following outcomes were reviewed and analyzed fourteen days before and after CGM placement: glucose levels (238 vs. 177 mg/dL), percentage of glucose levels within target range of 70-180mg/dL (31% vs 51%), average number of daily POC glucose checks (10.2 vs. 6.9), average amount of insulin received per day (0.42 vs 0.52 units/day), and average weight gain (11.4 vs. 20.7 grams/day). The discrepancy between POC and CGM glucose was also analyzed. CGM was within 20% of POC values 44% of the time and within 30% POC values 70% of the time. Adverse side effects of CGM were also noted. The patient was started on antibiotics following a small abscess identified underneath the CGM site. Bruising and skin breakdown were noted at the site, and the patient completed a course of antibiotics for the cutaneous infection. There were no other concerns of infection related to CGM for the first 2.5 months following CGM placement.

Conclusion
This case highlights that CGM can effectively be used to optimize glucose management in neonatal diabetes in a very low birth weight infant. However, the area where the CGM is placed needs to be monitored for signs of infection.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
PSUN336 Dietary sugar and protein differentially regulate the insulin and IGF1 homologs Dilp2 and Dilp6 in Drosophila.
Authors: Suzawa Miyuki , Hilovsky Dalton , McPherson Kyle , Bland Michelle 
Published: November 2022

Abstract
Growth deficits are frequently seen among children in resource-poor settings where malnutrition and chronic enteric infections are common. The insulin/IGF1 signaling pathway promotes cell and organismal growth across the animal kingdom. To better understand how malnutrition and infection impair growth, we investigated insulin/IGF1 signaling under such conditions using Drosophila as a model organism. In Drosophila, seven insulin-like peptides (Dilps) activate the insulin/IGF signaling pathway through a single known insulin receptor. Major circulating Dilps include Dilp2, produced from neurosecretory insulin-producing cells in the brain, and Dilp6, produced by the fat body, a functional analog of liver. Like insulin, mature Dilp2 lacks a C-peptide, whereas this sequence is retained in the IGF1 homolog Dilp6. We previously reported that bacterial infection and innate immune signaling negatively regulate whole-animal growth in Drosophila larvae by reducing circulating Dilp6 but not Dilp2. Here we asked whether Dilp2 and Dilp6 also respond differently to dietary sugar and protein, as secretion of insulin-like hormones is rigidly regulated by dietary nutrients. We used dual-epitope tagged Dilp2 and Dilp6 alleles to measure endogenous, circulating Dilp2 or Dilp6 in larvae. We find that circulating Dilp2 decreased by 60% after six hours of starvation on non-nutritive agar, and we observed a 90% decrease in Dilp2 from fed levels after 24 hours of starvation. In contrast, circulating Dilp6 was only reduced by 33% after 24 hours of starvation. Next, we asked whether Dilp2 and Dilp6 respond to specific dietary nutrients by adding yeast extract (to mimic the wild protein source) and/or sucrose to agar. Hemolymph Dilp2 was recovered to 73% of fed levels by the addition of yeast extract; addition of sucrose did not increase Dilp2 levels above the starved condition. Although the circulating level of Dilp6 was not strongly reduced by starvation, hemolymph Dilp6 was increased 40% by a sucrose-only diet compared with the normal, fed condition. Surprisingly, a yeast extract-only diet led to a 70% inhibition of circulating Dilp6 compared with the normal fed state. Addition of sucrose to the yeast diet led to a dose-dependent increase in Dilp6, suggesting that this hormone responds to the ratio of sugar to protein in the diet. Together, these data suggest that Dilp2 and Dilp6 secretion is controlled by distinct environmental conditions ranging from infection to dietary composition. An open question is how these two hormones carry distinct information to target organs despite binding to the single known insulin receptor encoded in the Drosophila genome.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
RF04 | PSUN298 Loss of β-Cell Glut2 Does Not Affect Systemic Glucose Homeostasis in Mice
Authors: Bathina Siresha , Bainbridge Lauren , Davis Autumn , Chhabra Kavaljit 
Published: November 2022

Abstract
Contribution of β-cell GLUT2 to systemic glucose homeostasis remains controversial in humans. For example, recent publications indicate that GLUT2 is not a major glucose transporter in β-cells in humans and therefore may not be involved in regulating systemic glucose homeostasis, which is in strong contrast to its previously assumed contribution to influencing systemic glucose balance. Although global Glut2 knockout mice develop diabetes, the contribution of β-cell Glut2 toward this phenotype is unknown. To determine the role of β-cell Glut2 in systemic glucose homeostasis, we crossed Glut2LoxP/LoxP mice with INSCreERT2 mouse strain to obtain mice that will potentially lack Glut2 specifically in β-cells (β-Glut2 KO) after administration of tamoxifen (100 mg/kg, i.p., once daily for five days) to induce the Cre-Lox recombination. We measured 6 h fasting blood glucose levels, glucose tolerance, and glucose-induced insulin secretion in the β-Glut2 KO mice. We observed that the KO mice had normal fasting blood glucose levels (male: 194.2 ±9.3 vs 192.0 ±3.5; female: 177.3 ±8.5 vs 157.3 ±9.8 mg/dL, Control vs. β-Glut2 KO). Similarly, the β-Glut2 KO mice exhibited normal glucose tolerance following oral administration of 60 mg glucose (Area under the curve for glucose tolerance, male: 39,911 ±1,632 vs. 39,633 ±1,275; female: 47,321 ±3,294 vs. 43,673 ±2,677 mg/dL*min, Control vs. β-Glut2 KO). Moreover, the KO mice had normal glucose-stimulated insulin secretion (baseline fasting plasma insulin levels: male - 0.84 ±0.14 vs. 0.5 ±0.01; female - 0.45 ±0.09 vs 0.48 ±0.1; plasma insulin levels 20 min. after oral glucose administration: male - 2.39 ±0.13 vs 2.48 ±0.51; female - 1.63 ±0.3 vs 1.11 ±0.12 ng/ml, Control vs. β-Glut2 KO). We had validated the loss of β-cell Glut2 using mRNA in situ hybridization. Altogether, our findings indicate that β-cell Glut2 is not essential for regulating systemic glucose homeostasis in mice, which was also observed recently with human β-cells. Therefore, the currently assumed major role of β-cell GLUT2 in directly influencing blood glucose levels needs to be reexamined to better understand the pathophysiology of impaired glucose homeostasis in diabetes.
Presentation: Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m., Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.
RF16 | PSUN177 Predictors of Postpartum Depressive Symptoms in Women with Recent GDM
Authors: Dias Jennifer , Nicklas Jacinda , Shqair Lara , Seely Ellen W 
Published: November 2022

Abstract

Background
Patients with gestational diabetes mellitus (GDM) have an increased risk of developing type 2 diabetes mellitus (T2DM) after delivery and are encouraged to practice behaviors, such as healthy nutrition, physical activity and weight loss to attenuate future risk of T2DM. GDM has been shown to significantly increase the risk for post-partum depressive symptoms, which can impair a woman's ability to engage in and adhere to diabetes prevention efforts. To further inform the development and adapation of lifestyle interventions to prevent T2DM, we sought to identify factors associated with depressive symptoms in the early postpartum period among women with recent GDM.

Methods
Participants are from the baseline cohort of the Balance after Baby Intervention study, a two-year randomized clinical trial of a lifestyle intervention for women with recent history GDM conducted in Boston, MA and Denver, CO between 2016-2019. Prior to randomization, a study visit was scheduled at approximately 6 weeks post-partum. At this visit, weight and height were measured for determination of BMI. We administered the Edinburgh Postpartum Depression Scale (EPDS) and Perceived Stress Scale (PSS-10). We used an EPDS score of ≥9 as depressive symptoms and a PSS score of ≥14 as moderate to high perceived stress. We collected self-reported pre-pregnancy weight, and reviewed medical records to obtain medical history, including GDM diagnosis, mode of delivery, gestational weight gain and insulin use during pregnancy. We conducted bivariate analyses to identify predictors of postpartum depressive symptoms, then modeled the odds of post-partum depressive symptoms using multivariate logistic regression.

Results
Our study included 181 women (mean age, SD 32.6 ± 5.3 years, 51.4% White/14.4% Black/33.7% Latinx, mean pre-pregnancy BMI 29.8 ± 6.0 kg/m2). 19% of women scored ≥9 on EPDS and 53% of women scored ≥14 on PSS at the post-partum visit. Variables included in the bivariate analysis were age, Black/Latinx-identifying, college completion, perceived stress, primiparity, having a partner, pre-pregnancy BMI, gestational weight gain, C-section, insulin use during pregnancy, breastfeeding, 1st GDM pregnancy, exceeding IOM weight gain guidelines and income level. Of those variables, the best fit multivariate model with the lowest Akaike information criterion (AIC) included perceived stress, C-section and 1st GDM pregnancy. Using this model, the regression analysis showed that only perceived stress (4.5 OR, 95% CI [2.6-7.7], p was predictive of post-partum depressive symptoms.

Conclusion
Perceived stress was predictive of post-partum depressive symptoms in women with recent GDM. Addressing perceived stress in the early post-partum period may be an important target for development or adaptations of future lifestyle interventions to prevent T2DM in women with recent GDM.
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 1:18 p.m. - 1:23 p.m.
RF16 | PSUN204 Improving Inpatient Insulin Management amongst Internal Medicine Residents with a Multi-Media Structured Educational Program
Authors: Pennant Marjorie , Park Jeayoung , Gothong Chikara , Ceipek Julian , Malek Rana 
Published: November 2022

Abstract

Introduction
Approximately 1 in 4 patients admitted to the hospital carry a diagnosis of diabetes mellitus1 and 1 in 10 patients are admitted due to diabetes complications.2 Although Internal Medicine residents comprise the primary care team for the vast majority of patients admitted to major academic hospitals, there is a paucity of resources and standardized training for inpatient diabetes management, specifically designed for residents.

Methods
We developed a structured resident education program consisting of a mobile/web application ("EndoApp") as an accessible resource combined with a series of short lectures. The EndoApp is comprised of checklists, guidelines, and calculators based on the most recent American Diabetes Association (ADA) and American Association of Family Physicians (AAFP) recommendations. The application addresses five major areas of inpatient insulin management—i) insulin pharmacokinetics, ii) admission dosage calculation, iii) inpatient insulin regimen adjustment, iv) management of diabetic emergencies, and v) equipment and prescription management at discharge. The confidence level of residents for each of the five areas were surveyed at months 0, 1, and 3, after the start of the program on a scale of 1-5.

Results
Our 3-month interim analysis showed that the confidence of residents in all five areas of inpatient insulin management improved over the study period. Increased confidence was seen in post-graduate year (PGY) 1, 2, and 3 residents. The Admission Insulin Dosing Calculator was the most frequently used function (45% of residents), followed by DKA/HHS helper (23% of residents), and Inpatient Dosage Adjustment Guidelines (21% of residents). Residents who used the Admission Insulin Dosing Calculator had greater increase in provider confidence compared to those who did not use the function. Subjective feedback from residents included expanding functions to include hypoglycemia and non-emergent hyperglycemia management, as well as having recordings of supplementary lectures available on the application.

Conclusion
Structured resident education in inpatient insulin management utilizing a mobile/web application and lectures as supplementary material is a promising approach to improve resident education and confidence in inpatient diabetes management.

References
1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American association of clinical endocrinologists and american diabetes association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4): 353-369. doi: 10.4158/EP09102.RA
2. Russell LB, Valiyeva E, Roman SH, Pogach LM, Suh DC, Safford MM. Hospitalizations, nursing home admissions, and deaths attributable to diabetes. Diabetes Care. 2005;28(7): 1611-1617. doi: 10.2337/diacare.28.7.1611
Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Sunday, June 12, 2022 12:30 p.m. - 12:35 p.m.