History Of Diabetes Mellitus Type Research Articles

“I WILL ONLY TAKE KLONOPIN!”; A CASE OF A 69-YEAR-OLD WOMAN WITH CO-OCCURRING SUBSTANCE USE DISORDER AND SCHIZOAFFECTIVE DISORDER, LIVING WITH HER 89-YEAR-OLD CAREGIVER

Introduction Geriatric psychiatric patients constitute a challenging population that requires special surveillance. Substance abuse is described as a growing, but frequently overlooked problem in this population (Kuerbis et al., 2014). According to Yarnell (2019), substance use disorders (SUDs) in later life is expected to double from 2.8?million in 2006 to 5.7?million in 2020, representing one of the fastest growing health problems in the country. SUDs are known to exacerbate co-occurring medical and psychiatric conditions in this vulnerable patient population, leading to increased hospitalization rates and healthcare costs, mechanical injuries, and cognitive impairment. Prescription medication abuse, compounded by polypharmacy, is especially hazardous in the elderly. Thus, effective identification and treatment of late-life SUDs is essential given the rapidly growing public health trend. The case report here highlights some of the challenges in managing co-occurring disorders in non-adherent older psychiatric patients and emphasizes the challenges associated with discharge planning, such as connecting geriatric patients to local mental health services within the community following short term hospitalization, housing arrangements for patients already domiciled in senior housing, and elder-to-elder abuse at home. Methods The specifics of this case report were reviewed in detail prior to summarizing the case and posing a meaningful discussion related to the relevant literature review and suggestions towards further research. Results MM is a 67-year-old Puerto Rican woman with past psychiatric history of schizoaffective disorder and hypnotic use disorder and past medical history of diabetes mellitus type 2 and hypertension domiciled in senior housing with her cognitively intact 89-year-old mother, who serves as her caregiver. The patient has a history of several emergency department visits and psychiatric admissions, and presented to the emergency department with paranoid ideation and aggressive behavior towards her mother. On initial evaluation, the patient was calm and cooperative, exhibiting paranoia associated with fearfulness and delusions of persecutory ideation toward her mother while referring to her as “the lady who is organizing a prostitution ring and making lies about me to send to the hospital”. The patient's mother reported that the patient exhibited assaultive behavior towards her, but the patient adamantly denied this. Collateral information confirmed the abuse of the mother along with history of paranoia towards neighbors, evidenced by persecutory delusions and subsequent threatening behavior. The patient was also reportedly approaching multiple practitioners, requesting prescriptions of benzodiazepines. During the hospital course, the patient displayed drug-seeking behavior demanding benzodiazepines “every 4 hours”. Patient was non-compliant with treatment during hospitalization stating she will only take Metformin and Klonopin, and a court order for treatment over objection was obtained. Once treated with Depakote, Invega, and Invega Sustenna the patient improved as she was notably less delusional and eventually stabilized for discharge. Issues which impacted discharge planning included potential homelessness if the patient was not allowed to live with her mother in her current senior housing; caregiver support to elderly; reluctance of elderly mother to have patient evicted from her apartment. Eventually a plan was formulated that included the patient returning to live with her mother in senior housing, court ordered outpatient treatment connection to assertive community treatment. A referral was also made to Adult Protective Services for the patient's mother. Conclusions This case highlights the importance of an interdisciplinary approach, including the coordination of mental health services between inpatient and community support services, consideration of approaching the court system for court-ordered medications in an older patient and managing geriatric psychiatric patients with comorbid substance abuse and history of violence. It is important to keep in mind that substance use disorders may be underdiagnosed and under-recognized in the aging population (Chhatre et al., 2017). Withdrawal from benzodiazepines may be unrecognized and complicate immediate and ongoing treatment of co-occurring conditions. Homelessness and impending homelessness due to interpersonal conflicts stemming from disruptive and aggressive behavior may further impact the care of this subgroup of patients. This research was funded by: Not applicable

Five-Year Glycemic Trajectories Among Healthy African-American and European-American Offspring of Parents With Type 2 Diabetes

Cross-sectional surveys report a higher prevalence of diagnosed type 2 diabetes mellitus (T2DM) in African Americans (AA) than European Americans (EA). We studied 5-year glycemic excursions among AA and EA in the Pathobiology of Prediabetes in A Biracial Cohort study, to assess ethnic disparities. Pathobiology of Prediabetes in A Biracial Cohort followed normoglycemic offspring of parents with T2DM for 5 years, with serial assessments of oral glucose tolerance test , anthropometry, body fat, insulin sensitivity and beta-cell function. The primary outcome was progression to prediabetes (impaired fasting glucose and/or impaired glucose tolerance). We further analyzed 5-year changes in fasting (FPG) and 2-hour plasma glucose (2hrPG). One hundred and one (52 AA, 49 EA) out of 343 subjects developed prediabetes during follow-up. The change in FPG ranged from -24 mg/dl to +38 mg/dl. The FPG remained stable (± 5 mg/dl from baseline) in 50% of EA and 46.8% of AA and the 2hrPG remained stable (± 25 mg/dl from baseline) in 73.7% of EA and 71.0 % of AA during follow-up. The proportions with change in FPG of 5mg/dl to >25 mg/dl and 2hrPG of 25 mg/dl to >50 mg/dl were similar in EA and AA offspring, as were the 10th - 90th percentiles of the distribution of 5-year changes in FPG and 2hrPG. During 5 years of follow-up, black and white offspring of parents with T2DM exhibited remarkable phenotypic concordance of glycemic trajectories. Thus, parental history of T2DM may be a stronger factor than race/ethnicity in the prediction of longitudinal glycemic trends.

The metabolic implications of aquaporin 7 (AQP7) promoter variants in lean children and children with obesity.

AQP7, a water/glycerol transporting protein, regulates adipocyte glycerol efflux and influences lipid and glucose homeostasis. Altered AQP7 expression in adults leads to impaired glycerol dynamics, adipocyte hypertrophy, and a predisposition to obesity and diabetes. AQP7 gene promoter variants lead to impaired AQP7-mediated adipocyte glycerol efflux and adipocyte hypertrophy. To assess its possible involvement in childhood obesity and metabolic abnormalities, the AQP7 promoter was studied in order to identify possible mutations and/or polymorphisms in children. Genomic DNA was extracted from the blood of 61 lean children (BMI < 85%) (46 prepubertal and 15 pubertal) and 41 children with obesity (BMI > 95%) (22 prepubertal and 19 pubertal). The samples were sequenced for AQP7 promoter region - 2580 (2421) to - 1161 (3840) using Automated Sanger sequence analysis. One novel mutation -2185 (T2816A) was found in an obese prepubertal child with low AQP7 mRNA expression, high levels of serum glycerol, and low serum insulin levels. The novel single nucleotide polymorphisms (SNPs) - 2291 (A2710G), - 2219 (C2782A), - 2091 (C2910A), and-1932 (G3069A) were identified, together with the previously described SNP -1884 (C3117T), rs3758268. The heterozygous state and the recessive allele of all four SNPs were related to a positive family history of diabetes mellitus type 2 (p = 0.001). The novel mutation -2185 (T2816A) might be associated with the lower gene expression of AQP7 and high levels of serum glycerol that possibly contribute to the obese phenotype. The heterozygous genotype of the four SNPs -2291 (A2710G), - 2219 (C2782A), - 2091 (C2910A), and -1884 (C3117T) in children may be related to a familial predisposition to diabetes mellitus type 2.

Impaired fasting glucose levels in overweight or obese subjects for screening of type 2 diabetes in Korea.

Background/AimsWe examined the concordance rate among fasting plasma glucose (FPG), 2-hour post-challenge glucose (2hr PG), and hemoglobin A1c (HbA1c) in the diagnosis of diabetes in a population with a high-risk for type 2 diabetes mellitus (T2DM) in Korea.MethodsAmong the participants from the Korean Diabetes Prevention Study, individuals with FPG ≥ 100 mg/dL, body mass index (BMI) ≥ 23.0 kg/m2, and no previous history of T2DM were consecutively enrolled after a 75 g glucose tolerance test. We analyzed the differences in the clinical characteristics in subjects with stage 1 (FPG, 100 to 109 mg/dL) and stage 2 (FPG, 110 to 125 mg/dL) impaired fasting glucose (IFG).ResultsOf 1,637 participants, 27.2% had T2DM and 59.3% had IFG and/or impaired glucose tolerance (IGT). The mean age was 55.0 ± 8.1 years and the mean BMI was 26.3 ± 2.7 kg/m2. Based on FPG criteria, 515 (31.4%) and 352 (21.5%) subjects were classified as having stage 1 and stage 2 IFG, respectively. The 19.0% of stage 1 and 43.5% of stage 2 subjects showed 2hr PG levels in the diabetic range. Even for those in the normal FPG range, 63 (9.5%) participants showed a 2hr PG level of ≥ 200 mg/dL. Of 446 subjects with newly-diagnosed diabetes, 340 (76.2%) showed FPG levels < 126 mg/dL.ConclusionsThe oral glucose tolerance test should be actively considered for Korean adults who are overweight or obese with the IFG range (FPG, 100 to 125 mg/ dL) to allow for early detection of diabetes and prompt intervention.

Wound Healing Efficacy of Re Cell Heal in a Diabetic Foot Infection Patient Diagnosed with Gas Gangrene – A Case Report

Gas gangrene is a rapidly progressive and bacterial infection that produces tissue gas in gangrene. The condition may result from ischemia, infection, or trauma or a combination of these processes. A 72-year-old woman with a 10 years history of type-2 diabetes mellitus (NIDDM) presented to the emergency department with a one-week history of left foot painful, swelling, redness, fever and foul-smelling discharge from wound. Wound infection of the left foot worsening progressing to gas gangrene that remains unhealed after a week to one month. She was diagnosed with Clostridium perfringens and Clostridial myonecrosis. The foot X-ray showed a 13 X 8.5 X 1.75 cm and is surrounded by callus under the 1st to 5th metatarsal heads (Figure 3a &amp; 3b). Computed tomography (CT) scan showed moderate air suggesting deep tissue infection, with multiple tiny gas bubbles within under the first metatarsal heads, concerning for gas gangrene. The patient was treated with Poly Herbal Formulation (PHF), Re Cell Heal 500 mg Capsule (PRANATHI HERBALS; License No. T-2265/Ayur/; Letter No 2884/ DA/2018) (p.o) twice a day, in addition to the (Topical) Wound Check Ointment (Letter No 4964/DA/2018) accompanied with debriment over a five (5) months, foot healed without amputation improved therapeutic outcomes, reduce fatalities caused by gas gangrene. Re Cell Heal helps to provide relief in the symptoms like swelling and pain in tissues. Recent scientific evidences and trials conducted on Re Cell Heal is a traditional and alternative medicine in wound therapy, gas gangrene and diabetic related foot problems holds good promise in the future safety without any side effects.

CORONARY ARTERY ECTASIA PRESENTING AS ACUTE CORONARY SYNDROME

Coronary artery ectasia (CAE) is a rare entity with an incidence of 0.3-5%. Atherosclerosis and vasculitis are the most common causes. A 47-year-old male with history of type-2 diabetes mellitus and dyslipidemia presented to our hospital with left sided chest pain for ten continuous hours. EKG

Association between the triglyceride to high-density lipoprotein cholesterol ratio and the risk of type 2 diabetes mellitus among Chinese elderly: the Beijing Longitudinal Study of Aging

ObjectiveTime-dependent covariates are generally available as longitudinal data were collected periodically in the cohort study. To examine whether time-dependent triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio could predict the future...

Lifelong Idiopathic Unilateral Diaphragmatic Paralysis With Recurrent Pneumonia: A Case Report

A 50-year-old woman was admitted to the emergency center with dyspnea, cough, and fever symptoms. She had a medical history of diabetes mellitus type II, rheumatoid arthritis, as well as several admission records due to aspiration pneumonia. The primary diagnosis was diabetic ketoacidosis and pneumonia. Normal breath sounds were reduced on the lower posterior right side of the thorax. A standard chest x-ray and lung Computed Tomography (CT) scan revealed collapse consolidation in the Right Lower Lobes (RLL) and Right Middle Lobes (RML). We here presented a case of unilateral diaphragmatic paralysis with a history of recurrent pneumonia.

The Influence of Family History of Type 2 Diabetes Mellitus on Positive Health Behavior Changes among African Americans.

Type 2 diabetes mellitus (T2DM) is a disease that affects the body's ability to metabolize glucose effectively. The disease is predicted to be prevalent in over 300 million people by the year 2030. African Americans (AA) have the highest prevalence rates of type 2 diabetes mellitus (T2DM) in the United States. Lifestyle modification and awareness of risk factors, including family history, are important aspects for prevention of developing T2DM. The purpose of this study was to understand if a family history of T2DM played an influential role in individuals making positive health behavior changes for T2DM prevention. The phenomenological study was grounded in the health belief model and also identified barriers associated with inactivity towards positive health behavior changes. Participants selected for this study were at least 18 years of age, self-identified as AA, self-reported a family history of T2DM, and were not diagnosed with the disease themselves. Transcriptions of twenty face-to-face interviews were analyzed via qualitative research software NVivo Version 12 for Mac. Participants demonstrated a strong awareness of T2DM with an accurate definition of T2DM and explanation of signs, symptoms, and prevention. Participants recognized family history as a risk factor in only 55% of the responses. However, family history played a major role in prevention in the lives of the participants. The participants reflected on personal barriers to health behavior changes and were encouraged to incorporate better life choices in their own lives. This research offers communities, healthcare providers, and stakeholders a better understanding of the importance of family history as a risk factor to T2DM as programs are developed to mitigate health disparities in the AA community.

Secukinumab-associated localized granuloma annulare (SAGA): a case report and review of the literature

Granuloma annulare (GA) is a benign, usually self-limited inflammatory skin dermatosis characterized clinically by pink-red to brown dermal papules or annular plaques. The main histologic feature is the presence of palisading or interstitial granulomas composed of necrobiotic collagen, elastic fibers, and mucin surrounded by a lymphohistiocytic infiltrate. Granuloma annulare is commonly associated with trauma, infections, diabetes mellitus, dyslipidemia, malignancy, thyroid disease, and a variety of medications. Two cases of GA have been reported in association with the use of secukinumab, a monoclonal antibody directed against interleukin 17A (IL17A), for the treatment of moderate-to-severe plaque psoriasis. We report the third case of secukinumab-associated GA in a 52-year-old woman with a history of diabetes mellitus type II, dyslipidemia, and non-alcoholic steatohepatitis. After four months of therapy with secukinumab, she presented with pink papules coalescing to plaques involving the antecubital fossae. Histology demonstrated a lymphohistiocytic palisading granuloma with central necrobiotic collagen and mucin, consistent with GA. Physicians should be aware of the possibility of GA developing in patients receiving secukinumab, especially in those with predisposing factors for GA. A better understanding of secukinumab-associated GA may lead to discoveries in GA pathogenesis and reveal broader immunomodulatory effects of secukinumab.

Polymorphism E23K KCNJ11 Gen as a Risk Factor of Diabetes Mellitus in Serawai Tribe Of Bengkulu

ABSTRACT&#x0D; &#x0D; Background: Type 2 diabetes mellitus (T2DM) is a multifactorial disease involving genetic and environmental factors. The E23K KCNJ11 gene polymorphism causes KATP canal overactivity, decreases cell membrane depolarization potential, and decreases insulin secretion. E23K polymorphism of the KCNJ11 gene as a risk factor for T2DM.&#x0D; Research Objective: This study aimed to analyze the E23K polymorphism of the KCNJ11 gene as a risk factor for T2DM in the Bengkulu Serawai.&#x0D; Method: This study is a case-control study. The subjects of the study were 100 people with T2DM patients as a case group (50 people) and Non-DM subjects with families who did not have a history of T2DM as a control group (50 people). Fasting blood glucose (GDP) was analyzed by spectrophotometry and E23K KCNJ11 gene by polymerase chain reaction fragment length polymorphism (PCR-RFLP). Data were analyzed by statistics.&#x0D; Results: The frequency of AA genotypes in cases was higher than the controls (12% and 8%) (p = 0.001). The frequency of A allele in the case was higher than the control (32% and 18%) (p = 0.017). The risk of T2DM on AA / GA genotypes was 4.75 times higher in cases than controls (p = 0,000, OR 4.75 95% CI 2.01-11.24). The risk of T2DM in A allele was 2.14 times higher in cases than in controls (p = 0.017, OR 2.14, 95% CI 1.11-4.15).&#x0D; Conclusion: E23K polymorphism of the KCNJ11 gene as a risk factor for T2DM in Bengkulu Serawai Tribe.&#x0D; &#x0D; Keywords: E23K gene KCNJ11, DMT2, Non-DMT2.&#x0D;

Relationship of C-peptide levels to duration of Type 1 diabetes - A study from Sindh, Pakistan.

Objective:To determine the relationship of C-peptide levels with duration of type 1 diabetes mellitus.Methods:This prospective study was conducted at Baqai Institute of Diabetology and Endocrinology (BIDE), Baqai Medical University (BMU), Karachi-Pakistan from December 2013 to December 2015. A total of 184 subjects were recruited during the study period, 100 in Group-A and 84 in Group-B. Subjects clinically diagnosed with type 1 diabetes Mellitus (T1DM) were categorized into two groups based on duration of diabetes: Group-A (with ≤1-year duration of diabetes) and Group-B (with >1-year duration of diabetes). Ninety-nine of the 100 enrolled subjects in Group-A were diagnosed as having T1DM, with one subject who presented at 11.9 years of age and diagnosed with T2DM excluded from this study. Blood samples were drawn for biochemical parameters. Data for baseline characteristics and clinical parameters (HbA1c and C-peptide) were obtained from hospital management system of BIDE.Results:Fifty-seven (57.6%) subjects in Group-A, and 39 (46.4%) in Group-B were males. Mean±SD duration of diabetes (years) was 0.64±0.6 (range 0-1) in Group-A, and 7.65±5.5 (range 1-23) in Group-B. Family history of T1DM and T2DM was 1(1%) and 27(27.3%) in Group-A, and 8(9.52%) and 21(25%) in Group-B, respectively. Twenty-one (21.2%) subjects presented in diabetic ketoacidosis (DKA) in Group-A and 18(21.4%), in Group-B. Mean±SD for HbA1c was non-significantly higher in Group-A 11.12±2.31 compared to Group-B 10.42±1.45. Mean±SD for C-peptide was 1.91±1.53 ng/mL (0.60±0.481 nmol/L) in Group-A, and 1.82±1.01 (0.57±0.32 nmol/L) in Group-B (p=0.984).Conclusion:The study found that subjects with longer duration of T1DM had non-significantly decreased C-peptide levels compared to a group in which C-peptide was measured at or soon after diagnosis. Furthermore, C-peptide levels in many subjects with longer duration were higher than expected in classic T1DM.

Heredity of type 2 diabetes confers increased susceptibility to oxidative stress and inflammation

Introduction and objectiveHeredity of type 2 diabetes mellitus (T2DM) is associated with greater risk for developing T2DM. Thus, individuals who have a first-degree relative with T2DM (FDRT) provide a natural...

Comparison of day-to-day blood pressure variability in hypertensive patients with type 2 diabetes mellitus to those without diabetes: Asia BP@Home Study.

Blood pressure variability (BPV) has been shown to be independently associated with cardiovascular (CV) mortality and morbidity. Patients with type 2 diabetes mellitus (T2DM) have also been shown to have increased BPV. We aimed to compare BPV in hypertensive patients with diabetes with those without diabetes. A total of 1443 hypertensive patients measured their blood pressure (BP) twice in the morning and twice before bed at home for a week. Demographic data, history of T2DM, and anti-hypertensive use were captured. Clinic BP was measured twice in the clinic. Control of BP was defined as clinic systolic BP (SBP) <140mmHg and home SBP<135mmHg. BPV was based on home SBP measurements. A total of 362(25.1%) hypertensives had diabetes and 47.4% were male. Mean age was 62.3±12.1years. There was no difference in the mean clinic SBP in both groups (139.9mmHg vs 138.4mmHg P=.188). However, the mean morning home SBP was significantly higher and control rate lower in hypertensives with diabetes than those without (132.3±15mmHg vs 129.7±14.4mmHg P=.005, 39.4% vs 47.6% P=.007), respectively. Masked uncontrolled morning hypertension was higher in those with diabetes versus those without (12.8% vs 8.4%, respectively). There was no statistically significant difference in BPV between those with and without diabetes. In summary, clinic SBP was similar in hypertensives with or without diabetes. However, control of BP based on both clinic and home SBP thresholds was poorer in hypertensives with diabetes compared to those without. Masked uncontrolled morning hypertension was higher in those with diabetes than those without. There was no difference in BPV between the two groups.

Prediction of perinatal complications of gestational diabetes

Aim. To develop a tool for the prediction of perinatal complications in pregnant women with gestational diabetes utilizing conventional and ultrasound markers of diabetic fetopathy.Materials and Methods. We analyzed 128 case histories of women who suffered from gestational diabetes. Among their newborns, 35 had clinical manifestations of maternal hyperglycemia (birth weight &gt; 90th percentile, neonatal hyperglycemia, respiratory distress syndrome, and neonatal jaundice) while 74 were free of the indicated signs and symptoms.Results. Risk factors of maternal hyperglycemia manifestations in neonates included family history of diabetes mellitus type 2, obesity, and pre-eclampsia. Maternal hyperglycemia was significantly associated with the higher risk of adverse perinatal outcomes. A combination of ≥ 4 ultrasound оценке markers of a diabetic fetopathy permitted the diagnosis of the fetal macrosomia. Conclusion. Ultrasound markers of diabetic fetopathy have limited sensitivity in the prediction of perinatal complications after gestational diabetes.

P.819 A comparative study of cognitive functioning in subjects with and without family history of diabetes mellitus type 2

P.819 A comparative study of cognitive functioning in subjects with and without family history of diabetes mellitus type 2

Unresponsive: A Case of Hyperglycemia and Altered Mental Status

Altered mental status is an emergency that significantly contributes to morbidity and mortality in children, and thus, requires rapid and thorough evaluation. Identification of the underlying cause of altered mental status is crucial for appropriate clinical management. With a presentation of hyperglycemia and a family history of diabetes mellitus type 2, an astute physician would consider metabolic encephalopathy as the cause of altered mental status. We describe a critical case of altered mental status in a 14-year-old obese male adolescent with no history of chronic illness or surgeries who presented to the emergency department with hyperglycemia.

Management of patients with type 2 diabetes mellitus in the Grand-Aides Program

Objective: To evaluate the Grand-Aides Program for patients with type 2 diabetes mellitus (T2DM) according to the variables of body weight, blood pressure, medication adherence, and hospital consultation and readmissions.Methods: Patients ages 18 years or older with a past medical history of T2DM, hypertension (HTN), and/or obesity and who were recently seen in the emergency department (ED) or recently admitted to the hospital were eligible to enroll in the Grand-Aides Program. Eligible patients were identified after hospital or ED discharge and were asked to enroll in the in-home based program from March 2016 through June 2018. In-home visit protocol was defined prior to patient enrollment with intense in-home visits during the first weeks of enrollment followed by monthly visits for the duration of enrollment in the program. In-home visit frequency was adjusted on as needed basis so that patients at higher risk for ED visits or hospitalization were seen more frequently. In-home visits were performed by trained Grand-Aide who for the purpose of this study was a certified nursing assistant (CNA). The Grand-Aide underwent eighty hours of didactic training which included visit protocols, visit schedules, and data collection. The one-on-one in-home patient with every visit were supervised by a registered nurse (RN) or nurse practitioner (NP) via video or telephone contact near the conclusion of the visit. Active patients at the University of Virginia Family Medicine clinic were eligible for enrollment. Fifty-seven patients with T2DM worked with Grand-Aides for three months and an additional forty-eight T2DM patients worked with Grand-Aides for twelve months. Emergency department visits, all 30-day hospital readmissions, as well as blood pressure readings, medication adherence, weights, and glycated hemoglobin (HbA1c) were compared with the prior twelve months.Results: Systolic (p &lt; .001) and diastolic (p &lt; .01) blood pressures decreased (p &lt; .01) at 1 year. At baseline 56 percent of the patients had a systolic blood pressure of &gt;130 mmHg despite treatment; after 12 months, 48 percent of these were &lt; 130. In those whose baseline diastolic blood pressure was &gt; 90 mmHg, 100 percent had diastolic blood pressure &lt; 90 mmHg at 1 year. Medication adherence by ARMS test at 1 year was 94 percent. Despite trending downward, weight and HbA1c did not change significantly. In the preceding, 58 percent had at least one ED visit, which was reduced by 50 percent (p &lt; .01) with Grand-Aides; 30-day all-cause readmissions reduced by 50 percent to 6.3 percent. Conclusions: The Grand-Aides program was associated with a significant change in blood pressure control, high medication adherence and reductions in ED visits and readmissions that compare favorably with published comparative data. For systems “at risk” for preventable increased health care expense burden, the Grand-Aides program can result in significant savings.

Hurricanes and healthcare: a case report on the influences of Hurricane Maria and managed Medicare in treating a Puerto Rican resident

BackgroundWhile Medicare is a federal health insurance program, managed Medicare limits access to healthcare services to networks within states or territories. However, if a natural disaster requires evacuation, displaced patients are at risk of losing coverage for their benefits. Previous literature has discussed the quality of managed Medicare plans within Puerto Rico but has not addressed the adequacy of this coverage if residents are displaced to the continental United States. We explore Hurricane Maria’s impact on a resident of Puerto Rico with chronic health problems, and the challenges he faces seeking healthcare in New York.Case presentationA 59-year-old male with a history of diabetes mellitus type II, coronary artery disease, peripheral vascular disease status post right foot amputation, and end-stage kidney disease on hemodialysis was admitted in October of 2017 for chest pain and swelling of legs for 5 days. The patient had missed his last three dialysis sessions after Hurricane Maria forced him to leave Puerto Rico. In examining this patient’s treatment, we observe the effect of Hurricane Maria on the medical management of Puerto Rican residents and identify challenges managed Medicare may pose to patients who cross state or territory lines.ConclusionsWe employ this patient’s narrative to frame a larger discussion of Puerto Rican managed Medicare and provide additional recommendations for healthcare providers. Moreover, we consider this case in the context of disaster-related continuity of care for patients with complex medical conditions or treatment regimens. To address the gaps in the care of these patients, this article proposes (1) developing system-based approaches for screening displaced patients, (2) increasing the awareness of Special Enrollment Periods related to Medicare among healthcare providers, and (3) creating policy solutions to assure access to care for patients with complex medical conditions.

INCIDENTAL LUNG MASS PRESENTING AS CRYPTOCOCCOMA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cryptococcus neoformans is one of the most common invasive fungal organisms worldwide and is associated with significant morbidity and mortality. Here, we present a case of a patient with a lung mass suspicious for malignancy but confirmed to be cryptococcoma. CASE PRESENTATION: 64-year-old male with past medical history of diabetes mellitus type 2, cirrhosis, obstructive sleep apnea, and testicular cancer presented to pulmonology clinic after he was found to have an incidental lung mass on imaging. His only complaint was shortness of breath. Initial CT of the chest with and without contrast showed a new 3.5 cm x 1.6 cm lobulated soft tissue density mass in the superior segment of the left lower lobe concerning for malignancy. QuantiFERON and fungal serology panel were negative. Biopsy was recommended but deferred by patient. Repeat CT chest 2 months after the initial CT showed interval enlargement of the mass to 3.8 cm x 1.7 cm. Transthoracic needle biopsy was pursued but did not reveal any malignancy or granulomatous inflammation. Tissue GMS and AFB stains were negative. Bacterial and mycobacterial cultures did not grow any organisms, however, fungal cultures grew Cryptococcus neoformans. Subsequent serum cryptococcal antigen was elevated at 1:8. He was started on fluconazole and was found to have subjective improvement in his shortness of breath at his next follow-up appointment. Serum cryptococcal antigen performed one month after starting fluconazole trended up to 1:32 and subsequently decreased to 1:16 at two months. Unfortunately, he was subsequently lost follow-up due to health insurance and financial issues. DISCUSSION: Pulmonary cryptococcal infection often presents a challenging diagnosis for clinicians as it can present with nonspecific signs and symptoms such as dry cough, fever, malaise, dyspnea, and pleuritic chest pain [1]. Clinical manifestations range from asymptomatic infection to disseminated or fulminant disease. The diagnosis is more difficult to make by the fact that radiographic findings of cryptococcal pneumonia are often highly variable. The radiographic pattern can also vary depending on immune function and duration of disease. Furthermore, only about half of patients have findings on imaging [1]. The most common radiographic findings are pulmonary nodules or masses regardless of immune status [2]. Diffuse lung involvement, reticulonodular interstitial infiltrates, and pleural effusions are more common among immunocompromised hosts [2-3]. Cavitary lesions are more common in the immunosuppressed but have been noted to occur in immunocompetent individuals as well [2]. CONCLUSIONS: The clinical and radiographic presentation of cryptococcal pneumonia is highly variable. Clinicians should keep high suspicion and consider cryptococcoma within the differential diagnosis of pulmonary masses regardless of patient immune function. Reference #1: Skolnik K, Huston S, Mody CH. Cryptococcal Lung Infections. Clinics in Chest Medicine. 2017;38(3):451-464. https://doi.org/10.1016/j.ccm.2017.04.007. Reference #2: Khoury MB, Godwin JD, Ravin CE, Gallis HA, Halvorsen RA, Putman CE. Thoracic cryptococcosis: immunologic competence and radiologic appearance. AJR Am J Roentgenol 1984; 142: 893–6. Reference #3: Lacomis JM, Costello P, Vilchez R, Kusne S. The Radiology of Pulmonary Cryptococcosis in a Tertiary Medical Center. Journal of Thoracic Imaging. 2001;16(3):139-148. https://doi.org/10.1097/00005382-200107000-00001. DISCLOSURES: No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by Johnathan Fagg, source=Web Response No relevant relationships by Mingchen Song, source=Web Response No relevant relationships by Saad Ullah, source=Web Response