Diabetes Hypertension Research Articles

6553 Remission of Cushing’s Disease on Day 6 Post Transsphenoidal Surgery

Abstract Disclosure: M.N. Abdou: None. H. Alhumaidi: None. Background: Current recommendations for steroids replacement in the immediate post-operative (post op) period after transsphenoidal surgery (TSS) for patients with Cushing’s Disease (CD) are heterogenous and can be misleading. Monitoring daily morning cortisol for 72 hours post TSS with replacing steroids only after detecting low morning cortisol or signs of adrenal insufficiency (AI) has been mentioned in several studies. While some studies recommend either empiric steroids replacement on discharge regardless of status of remission or longer hospital stay for closer cortisol monitoring, others recommended monitoring for 3-4 days and starting steroids on discharge only if morning cortisol was < 415 nmol/L. Case: 60 years old female with a history of type 2 diabetes mellitus, hypertension and dyslipidemia was referred for an evaluation of a pituitary macroadenoma. She had an incidental finding of a pituitary mass measuring 25 mm on a CT brain obtained after a fall 3 months prior to her current visit. MRI pituitary gland revealed a 25x23x22 mm suprasellar mass with cavernous sinus invasion. She reported weight gain and worsening of diabetes control over the 2 years prior to her presentation. On exam, weight was 80 kg, BMI 32.5, BP 110/69, vital signs were otherwise normal. She had central obesity, facial plethora, and frontal hair thinning. Hormonal workup showed elevated 1 mg dexamethasone suppression test: 341 nmol/L (<55). 24h UFC was also high 233 nmol/24 hours (38-208). Morning cortisol 15.5 mcg/dl (6-18) with ACTH 228 pg/ml (7.2-63.3). Prolactin 581 mIU/L (58-418). FSH and LH were at the premenopausal range. TSH, FT4, and IGF-1 were normal. HBA1C 8%. Results were consistent with CD with central hypogonadism and mild elevation of prolactin likely due to stalk effect. Patient was admitted to the hospital for TSS. She had no surgical complications, and no steroids were used to monitor remission. Daily morning cortisol was measured after the surgery, readings were (1631, 668, 469, 224, 318, 110 nmol/l) day 1-6 (D1-D6) post op. She was started on oral Hydrocortisone (HC) 15 mg in the morning and 10 mg in the afternoon on D6 post op after documentation of cortisol level of 110 nmol/l. She was vitally stable and had no signs of AI before starting steroids. 1 day after starting oral HC she developed hypotension and hyponatremia. IV HC 100 mg was given immediately followed by 50 mg every 6 hours. Blood pressure improved with stress dose steroids. She was discharged home on HC 20 mg three times daily, tapered to reach 15, 10 over a period of 2 weeks. Conclusion: We present a case of CD that had a nadir morning cortisol on D6 post op in whom a diagnosis of fatal AI would have been missed if recommendations from some studies were followed. This case highlights the importance of prolonged monitoring for adrenal insufficiency if steroids were not used after surgery for CD. Presentation: 6/1/2024

12406 Epidemiology Of Multiple Endocrine Neoplasia Type 1 In South Korea: A Nationwide Cohort Study

Abstract Disclosure: K. Kim: None. Y. Hwang: None. M. Yu: None. S. Moon: None. N. Hong: None. Y. Rhee: None. Multiple Endocrine Neoplasia Type 1 (MEN1) is one of the rarest endocrine disorders, with a scarcity of comprehensive epidemiological data globally. This deficiency in data is even more pronounced in Asian populations, where MEN1 remains an under-researched area. Therefore, our aim is to identity the prevalence, demographic characteristics, and patterns of comorbidities associated with MEN1.This nationwide cohort study assessed likely MEN1 cases from the Korean National Health Insurance Service database (2003-2020), selected via two operational definitions: one requiring an ICD-10 code for MEN1 (D44.8) and the other mandating at least two related procedures for MEN1-associated conditions (Primary Hyperparathyroidism, Pituitary Adenomas, and Duodenopancreatic Neuroendocrine Tumors). Cases were 1:10 matched by age, sex, and index year with controls who did not have any MEN-1 associated tumors. Our study evaluated 412 patients with likely MEN1 (mean age 43.6 ± 15.8 years; 35.4% male) against an age-sex matched control group of 4,120. Baseline characteristics showed a higher prevalence of comorbidities in MEN1 patients, including diabetes mellitus (22.6% vs 4.8%), hypertension (38.1% vs 16.4%), and dyslipidemia (20.6% vs 11.2%), all with p<0.001. Cancer prevalence was markedly elevated in MEN1 patients across most types, compared to controls. Adrenal involvements were observed in 34.7% of MEN1 patients, with adrenal adenoma being the most common (31.6%). Parathyroid, pituitary, and duodenopancreatic involvements were identified in 58.6%, 22.3%, and 19.9% of MEN1 patients, respectively. Mortality analysis revealed MEN1 patients had a higher mortality rate (16.0 per 1000 person-years) and a younger mean age at death (60.1 years) compared to controls (68.0 years), with an adjusted mortality hazard ratio of 3.1. Additionally, mortality risk varied with organ involvement; parathyroid involvement showed an adjusted HR of 2.7, pituitary involvement 4.7, and duodenopancreas involvement 4.0. The risk increased significantly with multi-organ involvement, where patients affected in more than two organs had HRs from 2.8 to 7.3. Our findings indicate that MEN1 significantly impacts patient morbidity and mortality, necessitating improved surveillance and tailored management to enhance early detection and optimize care for this vulnerable patient group. These insights underscore the pressing need for further research into MEN1 and other rare diseases to advance patient care and outcomes. Presentation: 6/2/2024

7013 An Inpatient Perspective: Hyperprolactinemia and Granulomatous Mastitis

Abstract Disclosure: A. Le: None. J. Wade: None. K. Martz: None. D. Girgis: None. M. Shahlapour: None. M.H. Horani: None. Introduction: Mastitis is a highly prevalent condition impacting thousands of women every year. Most commonly associated with lactation, mastitis is estimated to impact 2-20% of lactating women particularly in the first 4-6 weeks of breastfeeding (Wilson et al., 2020). The majority of cases are associated with bacterial infection with Staphylococcus aureus precipitated by nipple trauma and hyperlactation in the setting of genetic predispositions and disturbances to the human milk microbiota (Fernández et al., 2020). In rare cases, mastitis is seen outside of the context of lactation. One cause of non-lactational mastitis is idiopathic granulomatous mastitis (IGM). The pathogenesis of IGM is poorly understood, but there has been a rare association between IGM and hyperprolactinemia reported in the literature (Nikolaev et al., 2016). Case Presentation: In January 2022, A 20 year old female with past medical history of type 2 diabetes mellitus and hypertension, initially presented to the emergency department with complaints of headache. Patient’s history is notable for two years of amenorrhea and periodic nipple discharge. MRI scan of the head revealed a 1.6 cm pituitary macroadenoma which correlated with a markedly elevated prolactin level at 533.3. She was discharged with a prescription for Cabergoline 0.5 mg BID. In July 2022, the patient presented to the ED complaining of severe left breast pain with associated discharge for 4 days. She admitted to being non-adherent to Cabergoline treatment since April 2022 due to lack of endocrine follow-up. CT of the breast at that time showed a 3.8 cm subareolar abscess. Aspiration of the abscess revealed non-purulent fluid and cultures of the aspirate were negative. In February 2023, patient presented for right breast pain with a similar workup to previous hospitalization. MRI of the brain revealed a 1.6 cm sellar mass is unchanged since January 2022. Prolactin level was elevated at 652.4. Patient stated she has been off Cabergoline for the prior 5 months. She was subsequently seen for right and left mastitis 3 times over the next 12 months. Upon endocrine consultation, the patient was counseled on the importance of Cabergoline treatment in regression of future mastitis episodes, and the patient has subsequently not returned to our service. Conclusion: This case demonstrates the rare association between prolactin secreting pituitary adenomas and granulomatous mastitis that clinicians need to consider in order to avert delays in treatment and unnecessary hospitalizations. Specifically, when working up a patient with a history of IGM and prolactinemia, it is imperative to monitor prolactin levels periodically over an extended course of time with appropriate MRI imaging of the pituitary gland to assess for regression of prolactinoma and episodes of IGM. Presentation: 6/1/2024

7087 An Unusual Movement Disorder, Case of Diabetic Striatopathy!

Abstract Disclosure: S. Azmat: None. O. Lodhi: None. R. Safi: None. H. harb: None. H. Ashok: None. M.F. Siddiqui: None. J.L. Gilden: None. Background: Non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome (NKH-CB) is rare complication of poorly controlled diabetes mellitus (DM) characterized by continuous, irregular jerky movements localized to one side of the body. It is commonly seen in type 2 DM and is often presented in females of East Asian descent. NKH-CB is often misdiagnosed due to its rarity and radiographic features easily mistaken for intracerebral hemorrhage.Case: A 70-year-old Latino male with type 2 diabetes mellitus, hypertension, bipolar disorder and past history of two cerebrovascular accidents presented to ED with non-radiating, midsternal chest pain. ACS was ruled out with negative serial troponins and normal EKG. Vital signs were significant for elevated blood pressure 151/64 mmHg. Labs showed blood glucose=447 mg/dL. Physical examination revealed large amplitude involuntary movements in left upper and lower extremities and facial region. He also veered to the left when ambulating. The patient reported that these abnormal movements were occurring for last three weeks although sensation was preserved bilaterally. Code stroke was called; non-contrast CT showed unilateral hyper density of the right caudate and putamen with no evidence of acute intracranial hemorrhage or large arterial territory infarction. CT Angiogram did not show any signs of stenosis or occlusion. He received intravenous fluids and 8 units lispro insulin in ED. Was admitted for further evaluation and received basal/bolus insulin therapy with target blood glucose of 140-160 mg%. He also received risperidone for his mental condition. Subsequent testing revealed hemoglobin A1C of 16.9% (reference range: < 5.7%). MRI Brian showed unilateral T1 hyperintensity involving right caudate and putamen corresponding to the hypodensity seen on CT. Neurology service was consulted. Based on clinical signs/symptoms coupled with neuroimaging, he was diagnosed with non-ketotic Hyperglycemia Hemichorea-Hemiballismus Syndrome. On day 2 with resolution of hyperglycemia, amplitude and frequency of involuntary arm movements were minimal. The patient was discharged with Lantus 7 and metformin 1000 mg for DM and risperidone for symptoms management. Conclusion: Diabetic neuropathy is commonly known to result in small and/or large fiber sensorimotor polyneuropathy, proximal motor, and acute mononeuropathies as well as entrapments, radiculopathies, autonomic neuropathies, and even cognitive disorders. This case describes rare case of simultaneous NKH-CB with history of CVA and antipsychotic medication use in a patient with poorly controlled DM which resolved with treatment of hyperglycemia. Thus offers valuable insights into the diagnostic challenges associated with this condition as well as potential links to other neurological complications. One should also remain vigilant of potential onset of seizures commonly seen with NKH. Presentation: 6/3/2024

6661 Critical Limb Ischemia - An Unusual Presentation Of A Pheochromocytoma

Abstract Disclosure: S. Hassan: None. Background: Pheochromocytomas can lead to vasoconstriction and its various clinical manifestations due to excess catecholamine release. Critical limb ischemia as a clinical manifestation of pheochromocytoma has been reported sparsely. Clinical Case: A 43 year old female with a past medical history of type 2 diabetes mellitus, Turner syndrome, and hypertension presented to the emergency department with acute on chronic left leg pain. She underwent workup with a CT angiography of the abdomen with runoff for evaluation of her vessels, which revealed an occlusion of her left superficial femoral artery with chronic stenosis of the right femoral system. Multiple unsuccessful attempts were made at revascularization of her left lower extremity, including femoropopliteal bypass, with eventual left above knee amputation, multiple fasciotomies, and angiogram and stenting of multiple vessels. The patient was on a combined OCP (norethindrone-ethinyl estradiol) for hormone replacement for Turner syndrome for the past 30 years, and did not have a personal or family history of clotting disorders. She underwent a hypercoagulable workup which was negative. Echocardiogram was negative for thrombi and was otherwise unremarkable. Incidentally discovered on her initial CT angiography was a heterogeneously enhancing right adrenal mass, which was further delineated on a dedicated CT of the adrenals, which showed a 3.7 cm right adrenal mass with pre-contrast Hounsfield units measuring 46. Biochemical workup revealed a normal plasma renin activity and aldosterone, plasma metanephrine elevated to 5.20 nmol/L (range 0.00 – 0.49 nmol/L), plasma normetanephrine elevated to 4.95 nmol/L (range 0.00 – 0.89 nmol/L), 24 hour urine metanephrine elevated to 3830 ug/d (range 36-229 ug/d), and 24 hour urine normetanephrine 1733 ug/d (range 95 – 650 ug/d). She reports a diagnosis of hypertension at age 36, with no secondary workup pursued; she had suboptimal control on three separate medications, lisinopril, metoprolol, and hydrochlorothiazide. Her blood pressure and heart rate were noted to be labile during her aforementioned surgery. Alpha blockade with doxazosin was started based on her significantly elevated plasma and urine metanephrines and normetanephrines, with improvement in her blood pressure control. She was not found to have a definitive cause of her critical limb ischemia; she was noted to have atherosclerosis in the vessels of her lower extremities, and her chronic oral contraceptive use may also have played a role. However, OCPs are often reported to cause venous rather than arterial thrombi. Therefore, it can be inferred that the catecholamine excess from her presumed pheochromocytoma caused vasoconstriction which may have played a role in the development of her critical limb ischemia. Conclusion: Catecholamine excess that is resultant from a pheochromocytoma may manifest as critical limb ischemia. Presentation: 6/1/2024

7464 Delayed Diagnosis of Cushing’s Disease after Five Year History of Hirsutism

Abstract Disclosure: E. McBride: None. A.N. Davis: None. G. Elshimy: None. J. Vender: None. Introduction: Women may experience hirsutism for years before seeing a physician or before undergoing diagnostic testing. This case demonstrates that delayed workup of hirsutism can lead to delayed diagnosis and treatment of aggressive Cushing’s disease. Case: A 40-year-old African American female presented for initial evaluation with a 5-year history of hirsutism, which had never been evaluated, and a high cortisol level in the setting of type 2 diabetes mellitus and hypertension. She had a 60lb weight gain over 5 years, progressive hirsutism, easy bruising, and purple striae. Labs were significant for cortisol 23.86mcg/dL, ACTH 67pg/mL, HbA1c 8.9%, DHEAS 347mcg/dL, 17-OH progesterone 102ng/dL. A 1mg dexamethasone suppression test resulted in a non-suppressed cortisol of 12.64mcg/dL. She had an elevated 24 hour urine free cortisol level of 78mcg and an elevated midnight salivary cortisol with values of 474ng/dL and 396ng/dL. An 8mg dexamethasone suppression test resulted in a cortisol of 5.55mcg/dL. MRI brain pituitary protocol revealed a 6x4mm microadenoma of the pituitary gland. This is consistent with an ACTH producing pituitary adenoma (Cushing’s disease). The microadenoma was surgically removed by transsphenoidal approach. The pathology of the tumor revealed an elevated Ki-67 of 5%. Patient required hydrocortisone replacement for a couple of months that was later discontinued. Moreover, she is no longer on any medications for her diabetes, and her hypertension significantly improved postoperatively. Discussion: Hirsutism and androgen excess in women are most commonly caused by polycystic ovarian syndrome (PCOS). However, non-PCOS diagnoses, such as Cushing’s disease, should be considered as they are commonly missed due to lack of a pragmatic screening approach. Pituitary microadenomas are often benign, but 30-40% of cases are invasive and considered aggressive. Aggressiveness can be evaluated by using the tumor marker Ki67, which is a nuclear marker that reflects cell proliferation. While controversial, one proposed cutoff for aggressive pituitary adenomas is Ki67 ≥3%. The pathology of the tumor in this patient was aggressive with Ki67 of 5% This case demonstrates the importance of identifying hirsutism early in order to exclude the more dangerous causes of hirsutism such as Cushing’s disease. By early diagnosis and surgery, we may limit the progression of associated comorbidities such as diabetes mellitus and limit the growth of a potentially aggressive adenoma. Presentation: 6/1/2024

12355 An Adolescent Female With Congenital Lipodystrophy Presenting With Repeated Acute Metabolic Decompensations Rescued By A Novel Leptin Receptor Agonist

Abstract Disclosure: D.M. Chambers: None. Y. Chan: None. M.K. Crocker: None. Patient SH is a now 17-year-old female treated for generalized congenital lipodystrophy with a course complicated by severe hypertriglyceridemia, type 2 diabetes mellitus, hypertension, hepatosteatosis, and intermittent menstrual irregularity. She had been managed successfully with metreleptin for 2 years, but in 2022-2023, she developed repeated episodes of pancreatitis (4 times over a 14-month period) secondary to severe hypertriglyceridemia (serum triglycerides >8000 mg/dL). During her admissions, she had markedly increased insulin requirements (up to 12 units/kg/day) with refractory hyperglycemia despite maximal treatment with metreleptin, empagliflozin, and oral semaglutide. In the clinical context of her acute metabolic worsening, she was suspected of having a neutralizing antibody against metreleptin. Serum leptin was undetectable 1 hour after observed metreleptin doses; direct measurement of neutralizing antibodies is pending. She was transitioned from metreleptin to mibavademab, an investigational leptin receptor agonist, on an expanded use IND. She subsequently experienced significant improvements in her fasting triglyceride levels (<300 mg/dL) with no subsequent episodes of pancreatitis since starting therapy in August 2023. She has also had improvements in other aspects of her metabolic health including decreased insulin requirements with decreasing hemoglobin A1c, decreased need for adjunctive lipid and hypertension therapy, and improving menstrual regularity. Her clinical course demonstrates: 1) clinical indicators of a rare but serious loss of efficacy of metreleptin therapy; 2) adjunctive options for management of generalized lipodystrophy; and, 3) an individual experience with a novel leptin agonist therapy in the treatment of generalized lipodystrophy. Presentation: 6/3/2024

6853 A Curious Case of MACS

Abstract Disclosure: M. Dillon: None. A. Syeda: None. V. Kantorovich: None. Introduction: Mild autonomous cortisol secretion (MACS) is characterized by biochemical evidence of mild hypercortisolemia inducing metabolic comorbidities without any obvious phenotypic stigmata of Cushing’s syndrome (CS). This case highlights the challenges faced in the diagnosis and management of MACS. Case: A 76-year-old female with past medical history of class II obesity (BMI 31.83 kg/m2), type 2 diabetes mellitus, hypertension, hyperlipidemia, osteoporosis and chronic kidney disease stage IIIb was diagnosed with MACS after an overnight 1 mg dexamethasone suppression test (DST) showed unsuppressed 8 AM cortisol of 2.4 mcg/dL (<1.8 mcg/dL). Dexamethasone level was appropriate at 355 ng/dL (180-550 ng/dL), ACTH was <5 pg/mL (6-50 pg/mL) and DHEA-S was normal. Late night salivary cortisol (LNSC) levels were elevated to 0.12 mcg/dL (< 0.09 mcg/dL). The 24-hour urine cortisol level was normal. Baseline 8 AM cortisol level was 17 mcg/dL and ACTH was 19 pg/mL. Abdominal CT scan showed a 1 cm left adrenal nodule of 25 HU density and a normal right adrenal with no atrophy. Phaeochromocytoma and primary hyperaldosteronism work up was negative. She started on Mifepristone 300 mg daily and titrated up to 600 mg daily. She presented to our institution one month later with 1 week of nausea, vomiting and muscle weakness. Laboratory studies revealed acute kidney injury with creatinine of 6.69 mg/dL (baseline Cr 1.5 mg/dL) and rhabdomyolysis with creatinine kinase level of 12,819 U/L (24-173 U/L) and urine myoglobin level of 888 ng/mL (0-13 ng/mL). It was evident that her catastrophic presentation was from development of adrenal insufficiency in the setting of Mifepristone glucocorticoid receptor blockade. The drug was discontinued immediately. She was treated with intravenous hydration and intermittent diuretics. Over 10 days, her clinical status gradually improved and creatinine decreased to baseline levels. Discussion: MACS is a challenging diagnosis as cortisol levels are affected by several variables including obesity, drugs, and poorly controlled diabetes. Hence, a meticulous evaluation is mandated before confirming the diagnosis. Our patient’s baseline cortisol and ACTH levels were normal, and her DST and LNSC levels were mildly elevated. Unilateral cortisol producing adenoma causes contralateral gland atrophy due to suppressed ACTH. This was not evident in our patient, thus making the diagnosis questionable. Adrenalectomy is the treatment of choice in MACS with adrenal adenoma. Off label medical management with Mifepristone, a glucocorticoid receptor antagonist, is being pursued in select cases and was trialed due to our patient's age and surgical risk. Mifepristone is approved for the treatment of hyperglycemia due to CS. The data supporting its use in MACS is sparse. Therefore, it is important to be aware of associated risks of Mifepristone when advising patients. Presentation: 6/3/2024

Prevalence of Hypertension in Type 2 Diabetes Mellitus in the Working Area of Jatibaru Community Health Center in 2023

The World Health Organization (WHO) predicts an increase in the number of diabetes mellitus sufferers in Indonesia from 8.4 million people in 2000 to around 21.3 million people in 2030. The prevalence of type 2 diabetes increases with age and changes in unhealthy lifestyles. Several studies show that the incidence of hyperglycemia in diabetes is closely related to hypertension. According to the American Diabetes Association (ADA) 2017, two out of three people with diabetes have high blood pressure. At the Jatibaru Community Health Center, based on 2023 data, it is known that hypertension and diabetes are always included in the data on the 10 most common diseases every month. Based on this background and related to the incidence of Hypertension and type 2 diabetes mellitus is still relatively high, so researchers are interested to knowing the picture hypertension in type 2 diabetes mellitus in the Jatibaru. This research is a descriptive study with a cross-sectional approach using secondary data taken from Non-Communicable Disease data. The population in this study were all adult and elderly respondents registered in the non-communicable disease program register, who based on anamnesis, physical and laboratory examination, were diagnosed with type 2 diabetes mellitus and hypertension. The sample was taken by purposive sampling. In this research, it was found that people with hypertension and diabetes mellitus were found in all adult and elderly age categories. The distribution of hypertension and type 2 diabetes mellitus patients continues to increase with increasing age, the prevalence of sufferers being more female than male. As many as 65% of the total type 2 diabetes mellitus sufferers also experience hypertension.

The biomarkers associated with non-dipper pattern in patients with type 2 diabetes with hypertension.

The non-dipper pattern is present in about 50 percent of patients with type 2 diabetes (T2D) and hypertension, a status associated with more frequent cardiovascular complications and restrained prognosis. This study aimed to identify simple biomarkers that can be used for the classification of dipper and non-dipper individuals with type 2 diabetes and hypertension. 138 consecutive patients with type 2 diabetes mellitus (DM) and hypertension underwent 24-hour ambulatory blood pressure monitoring (ABPM), 54 (39.1%) dippers and 84 (60.9%) non-dippers; CBC and determinations of different biomarkers, as well as their ratio was also performed, for comparing the two dipper profiles. The different dipper profiles were established by ABPM, which highlights the mean arterial pressure (MAP), the mean heart rate (MHR), and the mean pulse pressure (MPP). The area under the receiver operating characteristic curve (AUC) was used to evaluate the ability of biomarkers to differentiate dippers from non-dippers. The study included 54 dipper and 84 non-dipper patients. The median age was 64 years (interquartile range 58-74), ranging from 24 to 85 years. The comparison between dipper and non-dipper in patients with type 2 diabetes and hypertension concerning different biomarkers found only two that were statistically significant: triglycerides to hemoglobin A1c (HbA1c) ratio and triglycerides to glucose ratio. For both biomarkers, the dippers had higher values than non-dippers. The best AUCs were found for triglycerides (Trig) to glucose ratio of 0.774 (95% confidence interval 0.601 - 0.92), statistically significant, followed at a distance by lymphocytes, platelets-lymphocytes ratio (PLR), platelet distribution width (PDW-SD), mean platelet volume (MPV) /Lymphocytes, and others, none of them being statistically significant. This study offers valuable insights into the classification of dipper and non-dipper individuals with type 2 diabetes and hypertension using several biomarkers. Notably, the triglyceride-to-glucose ratio appeared as a significant marker with considerable discriminative capacity, indicating its potential therapeutic value in risk stratification and personalized treatment strategies.

B-294 Case report: Postmortem ethanol production following traumatic injury

Abstract Background Ethanol is the most commonly encountered psychoactive substance in forensic toxicology. Accurate interpretation of ethanol concentrations from postmortem samples is fraught with potential hurdles, including decomposition, redistribution, and postmortem production of ethanol. Through the fermentation of substrates like glucose, pyruvate, lactate, and amino acids, microorganisms present in the gut and/or environment can generate ethanol in contaminated human tissues, especially following traumatic injury. The degree of fermentation varies widely depending on the time between death and autopsy, temperature, humidity, tissue glucose concentrations, and the specimen type. Vitreous humor (VH) is the preferred specimen for postmortem toxicological analysis of ethanol because it accurately reflects the antemortem ethanol concentration in serum while being resistant to microbial contamination. This case highlights the utility of VH in an extreme instance of postmortem ethanol production. Methods Postmortem toxicological analysis of liver tissue and VH (NMS Labs, Horsham, PA) was performed by headspace-gas chromatography (HS-GC) Results Case presentation: A man in his sixties with a history of type 1 diabetes mellitus and hypertension was involved in a fatal mining accident while operating heavy machinery in which the equipment fell down a cliff, causing the man to be ejected onto the ground nearby. The decedent was discovered hours after the fall with extensive traumatic injuries to the left side of his body and head. Seven days later, an autopsy was performed by the medical examiner’s office. Postmortem toxicological analysis of liver tissue by HS-GC revealed ethanol at a concentration of 690 mg/100g. The liver tissue also tested positive for amlodipine, nicotine, cotinine, and caffeine. A vitreous humor (VH) sample tested negative (<10 mg/dL) for ethanol. Conclusions The toxicological findings reported herein are inconsistent with antemortem alcohol consumption and are instead an example of severe postmortem ethanol production by microbial contamination. Several factors likely led to the stark discrepancy between the concentrations of ethanol in VH and liver tissue. First, the decedent suffered traumatic injuries, creating conditions favorable for extensive microbial contamination. Second, the time between death and autopsy was seven days, allowing ample time for fermentation to occur, even under refrigerated conditions. Third, postmortem glycogenolysis in addition to the patient’s underlying T1DM likely provided a high concentration of glucose to fuel postmortem fermentation. Ultimately, this case underscores the importance of forensic specimen selection in accurately interpreting toxicology findings following traumatic injury.

Double burden of gestational diabetes and pregnancy-induced hypertension in Ethiopia: A systematic review and meta-analysis of observational studies.

The coexistence of gestational diabetes mellitus (GDM) and pregnancy-induced hypertension (PIH) amplifies the risk of maternal and perinatal mortality and complications, leading to more severe adverse pregnancy outcomes. This systematic review and meta-analysis aimed to assess the double burden of GDM and PIH (GDM/PIH) among pregnant women in Ethiopia. A comprehensive systematic search was conducted in the databases of PubMed, Cochrane Library, Science Direct, Embase, and Google Scholar, covering studies published up to May 14, 2023. The analysis was carried out using JBI SUMARI and STATA version 17. Subgroup analyses were computed to demonstrate heterogeneity. A sensitivity analysis was performed to examine the impact of a single study on the overall estimate. Publication bias was assessed through inspection of the funnel plot and statistically using Egger's regression test. Of 168 retrieved studies, 15 with a total of 6391 participants were deemed eligible. The pooled prevalence of GDM/PIH co-occurrence among pregnant women in Ethiopia was 3.76% (95% CI; 3.29-4.24). No publication bias was reported, and sensitivity analysis suggested that excluded studies did not significantly alter the pooled prevalence of GDM/PIH co-occurrence. A statistically significant association between GDM and PIH was observed, with pregnant women with GDM being three times more likely to develop PIH compared to those without GDM (OR = 3.44; 95% CI; 2.15-5.53). This systematic review and meta-analysis revealed a high dual burden of GDM and PIH among pregnant women in Ethiopia, with a significant association between the two morbidities. These findings emphasize the critical need for comprehensive antenatal care programs in Ethiopia to adequately address and monitor both GDM and PIH for improved maternal and perinatal health outcomes.

Associations between periodontal disease severity and selected cardiometabolic risk factors.

To explore associations between periodontal disease (PD) severity and cardiometabolic risk factors, including body mass index (BMI), age, Type 2 Diabetes Mellitus (T2DM) risk, sex, and hypertension (HTN) in patients at an urban dental school clinic. A cross-sectional study design was used to analyze electronic health record data, including periodontal status, demographic characteristics, cardiometabolic risk factors and the American Diabetes Association Diabetes Risk Test (DRT) Score. Chi-square tests and ordinal logistic regression were conducted using SAS 9.4. Of those with available data (n&#61;6,778), 44% were male, 70.2% were overweight/obese, and the mean age was 50.9 (SD&#61;16.6) years. Associations between PD severity and BMI, sex, age, DRT score, and HTN were statistically significant (all p<0.0001) in bivariate analyses. Using logistic regression, HTN (p&#61;0.0006), sex (p<0.0001), and age (p<0.0001) were significant predictors of severe PD which was most common in those with HTN (35.9%), males (31.7%), those >60 years (36.6%). The odds of having severe PD for those with HTN were 1.2 times that of those without HTN. Males were 1.7 times more likely to have severe PD than females. Those aged 40-49 years, 50-59 years, and >60 years were 2.9, 4.2, and 4.3 times more likely to have severe PD than those who were 18-39 years, respectively. All cardiometabolic risk factors were associated with PD severity in bivariate analyses. In the logistic regression model, being older, male, and having HTN were significant predictors of PD severity. Future research is needed with a more diverse sample.

Use of strain imaging to detect subtle myocardial involvement in post COVID-19 patients: An Indian perspective

BackgroundThe study assessed Global longitudinal strain imaging (GLS) to detect subtle myocardial dysfunction among patients clinically recovered from COVID-19. MethodsAll patients (n = 101 76 % males, mean age 55.45 ± 11.14 years), and controls (n = 30), underwent clinical assessment and echocardiography, including GLS assessment. ResultsThe prevalence of diabetes mellitus, hypertension and dyslipidemia was comparable amongst patients and controls. The average GLS was significantly lesser in post COVID patients (−16.21 ± 1.96 vs −18.49 ± 1.64 respectively, p = 0.004) and significantly higher proportion of post COVID patients had GLS > -18 % (43 % vs 22.58 % respectively, p = 0.001) as compared to controls. The RV free wall longitudinal strain (RVFLS) was also lower in the patient group (22.35 ± 4.69 vs 24.19 ± 4.11, p = 0.004) and 21.7 % post COVID-19 patients had pathological RV FWLS (> −20 %) vs controls (6.6 %).Average GLS was significantly lesser in severe post COVID patients (viz −14.25 ± 1.92 vs −16.63 ± 1.61 vs −17.63 ± 1.91, p < 0.0001, respectively among severe, moderate and mild COVID-19 patients. On performing regression analysis, severity of COVID-19 (OR 7.762) was a significant predictor of impaired GLS. ConclusionDespite normal global LVEF, post COVID-19 recovered patients had significantly lower LV GLS and RV FWLS with severe COVID-19 infection, regardless of having a clinical recovery. This study reiterates the importance of speckle tracking echocardiography as an important imaging modality for detection of subclinical myocardial dysfunction in the post COVID-19 recovered patients.

Preliminary study of the role of inner ear proteins in vestibular neuritis

ObjectiveTo evaluate the plasma levels of the otoconial proteins, otoconin-90 and otolin-1, in individuals diagnosed with vestibular neuritis (VN) and determine the feasibility of using these proteins as biomarkers for VN. MethodsIn this preliminary study, 30 patients diagnosed with VN and 70 healthy individuals were recruited and followed to confirm whether they had benign paroxysmal positional vertigo (BPPV) during the following time. The recorded data included measurements of height, weight, and history of diabetes mellitus or hypertension. Additionally, levels of plasma otoconin-90, and otolin-1 were measured and compared. ResultsThe plasma concentrations of otoconin-90 and otolin-1 may not be significantly different between patients with VN and healthy controls, nor among patients with BPPV secondary to VN and patients with VN without BPPV. ConclusionsPlasma otoconin-90 and otolin-1 levels may not serve as biomarkers of acute VN episodes or predict BPPV occurrence secondary to VN.

Impact of antiplatelet and anticoagulant drugs on postoperative bleeding in reverse total shoulder arthroplasty

BackgroundThe decision to withdraw or continue antiplatelet and anticoagulant drugs would be balanced on the bleeding risk and the cardiovascular risk. The purpose of this study was to investigate perioperative bleeding in reverse shoulder arthroplasty (RSA) to determine the impact of oral antiplatelet and anticoagulant medications in the absence of drug withdrawal. The hypothesis was that the continuation of antiplatelet and anticoagulant drugs would increase postoperative bleeding but to a limited extent. MethodsDuring the study period, RSA cases were prospectively included and retrospectively reviewed. Cases of revision for arthroplasty, proximal fracture, and cemented stem fixation were excluded. Cases with dual therapy of aspirin and clopidogrel and cases with heparin bridges were also excluded. Age, gender, height, weight, American Society of Anesthesiologists physical status anesthesia risk (ASA), smoking status, preoperative diagnosis, preoperative blood sampling data within one month of surgery (estimated glomerular filtration rate (eGFR), Prothrombin Time-International Normalized Ratio (PT-INR), and activated partial thromboplastin time (APTT)), surgical time, stem length (standard or short stem), and use of tranexamic acid were identified. The presence of diabetes mellitus, rheumatoid arthritis, and hypertension were confirmed as comorbidities. Hemoglobin (Hb) and hematocrit (Ht) values were recorded preoperatively and on the third postoperative day, and estimated blood loss was calculated by Gross formula using the change in preoperative Ht and postoperative day 3 Ht values. Multiple regression models were used to determine predictors of the estimated blood loss. P values less than .05 were considered statistically significant. Results315 RSA cases were analyzed (172 females, a mean age of 77.2 years). The estimated blood loss was 819 ml. The regression equation was statistically significant (P < .0001, R2=0.21), and aspirin, direct oral anticoagulants (DOAC), tranexamic acid, height, and surgery time were statistically significant explanatory variables, showing the predicted changes in bleeding volume for each drug were +283 ml for aspirin, +180 ml for DOAC, and -237 ml for tranexamic acid, respectively. Warfarin and cilostazol were not employed due to P values and Akaike's Information Criterion. Two blood transfusions (without antiplatelet or anticoagulant medications) were administered. One patient on aspirin had a cardiovascular event. ConclusionsThe current study showed that the use of aspirin and DOAC were significant predictors of increased perioperative blood loss, but the amount of increase was in the acceptable range, suggesting that continued antiplatelet and anticoagulant were relatively safe in primary RSA. Administration of tranexamic acid was shown to reduce bleeding significantly.

Interplay of Statins, Clopidogrel, and Repaglinide: Unraveling the Nexus of Hypoglycemia and Myopathy in a Geriatric Type 2 Diabetes Patient: A Case Report

Abstract Background: The management of cardiovascular diseases often includes the use of statins, which, while reducing cardiovascular risk, can interact with other medications leading to significant adverse effects. This case report explores the complex interactions between atorvastatin, clopidogrel, and repaglinide, which precipitated severe hypoglycemia and myopathy in a patient with multiple comorbidities. Case Presentation: We describe a 68-year-old female with a history of type 2 diabetes mellitus, hypertension, and ischemic heart disease, who developed severe hypoglycemia and myopathy following the adjustment of her statin therapy post-cardiac diagnosis. Her treatment regimen was modified to include an increased dose of atorvastatin and the introduction of clopidogrel, shortly after which she presented with hypoglycemia and symptoms of myopathy. Investigations revealed significantly elevated muscle injury markers and magnetic resonance imaging findings consistent with myositis. Discussion: The pharmacokinetic interactions between clopidogrel with repaglinide and repaglinide with atorvastatin exacerbated by the increased dose of atorvastatin, likely led to the observed clinical manifestations. This case highlights the critical need for careful monitoring of drug interactions, especially in patients with polypharmacy. Adjustments in drug dosages and consideration of alternative medications with fewer interaction risks are essential components of managing similar cases. Conclusion: This case underscores the importance of vigilant therapeutic management and individualized patient care in the context of complex drug regimens. Understanding and anticipating drug interactions can prevent significant adverse effects and improve patient outcomes in a population at high risk of polypharmacy complications.

Early Identification and Management of Chronic Kidney Disease: A Narrative Review of the Crucial Role of Primary Care Practitioners.

Early-stage (stage1-3) chronic kidney disease (CKD) has an asymptomatic presentation such that most people with CKD are unaware of their disease status and remain undiagnosed. CKD is associated with multiple long-term conditions (MLTC), or multimorbidity, the most common of these being cardiovascular disease, hypertension, and type2 diabetes. Primary care practitioners (PCPs) are crucial in the early identification and management of patients with CKD. For individuals at high risk of CKD, measurements of estimated glomerular filtration rate, urine albumin-creatinine ratio, and blood pressure should be obtained regularly and recorded in a timely manner. The importance of lifestyle changes in the prevention and management of CKD should also be highlighted. A recent addition to the treatment of CKD in people with and without type2 diabetes has been the recommendation by clinical practice guidelines of a sodium-glucose co-transporter2 (SGLT2) inhibitor alongside a renin-angiotensin-aldosterone system inhibitor as foundational therapy. SGLT2 inhibitors prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality, and they have a favorable safety and tolerability profile. However, uptake has been slow, particularly in people with CKD without type2 diabetes. A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection. Measures to raise awareness of the importance of early identification and intervention include local/national campaigns via social media and practice-based education; clinical education programs; integration of clinical decision support tools into electronic health records; detection programs built around electronic health records; and good interdisciplinary communication. PCPs at the forefront of multidisciplinary care are best placed to implement the evidence-based clinical practice CKD guidelines for lifestyle modification and guideline-directed medical therapy.

Male Gender Expressivity and Diagnosis and Treatment of Cardiovascular Disease Risks in Men

Male gender expressivity (MGE), which reflects prevalent sociocultural pressures to convey masculinity, has been associated with health. Yet, little is known about associations of MGE with the diagnosis and treatment of modifiable cardiovascular disease (CVD) risks. To investigate associations of MGE with modifiable CVD risk diagnoses and treatment in men. This population-based cohort study included data from waves I (1994-1995), IV (2008-2009), and V (2016-2018) of the US National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants were male adolescents (age 12-18 years) followed up longitudinally through younger adulthood (age 24-32 years) and adulthood (age 32-42 years). Data were analyzed from January 5, 2023, to August 28, 2024. Male gender expressivity was quantified in adolescence and younger adulthood using an empirically-derived and validated measurement technique that incorporates participants' responses to existing Add Health survey items to capture how similarly participants behave to same-gendered peers. Outcomes included self-reported diagnoses of CVD risk conditions (hypertension, diabetes, or hyperlipidemia) in adult men with elevated blood pressure, hemoglobin A1c, or non-high-density lipoprotein cholesterol levels, and self-reported treatment with antihypertensive, hypoglycemic, or lipid-lowering medications in adults reporting hypertension, diabetes, or hyperlipidemia. Multivariable regression was used to examine associations of adolescent and younger adult MGE with adult CVD risk diagnoses and treatment, adjusting for sociodemographic covariates. Among 4230 eligible male participants, most were non-Hispanic White (2711 [64%]) and privately insured (3338 [80%]). Their mean (SD) age was 16.14 (1.81) years in adolescence, 29.02 (1.84) years in younger adulthood, and 38.10 (1.95) years in adulthood. Compared with participants whose younger adult MGE was below average, those with higher younger adult MGE were overall less likely to report hypertension (22% vs 26%; P < .001), diabetes (5% vs 8%; P < .001), and hyperlipidemia (19% vs 24%; P < .001) diagnoses and diabetes treatment (3% vs 5%; P = .02) as adults. In multivariable models, every SD increase in adolescent MGE was associated with lower probabilities of adult hypertension treatment (MGE,-0.11; 95% CI, -0.16 to -0.6) and diabetes diagnoses (MGE, -0.15; 95% CI, -0.27 to -0.03). Higher younger adult MGE was associated with lower probabilities of adult hypertension diagnoses (MGE, -0.04; 95% CI, -0.07 to -0.01), hypertension treatment (MGE, -0.07; 95% CI, -0.13 to -0.01), and diabetes treatment (MGE, -0.10; 95% CI, -0.20 to -0.01). Adolescent and younger adult MGE outcomes were not associated with other adult CVD outcomes. In this cohort study of US males, higher adolescent and younger adult MGE was associated with lower adult hypertension and diabetes diagnoses and treatment. These findings suggest that males with high MGE may bear distinctive risks and correspondingly benefit from tailored public health efforts to prevent downstream CVD.

Gestational weight gain and body mass index in Asian Indian women: Impact of timing and amount on fetomaternal outcomes

ABSTRACT Background: The aim of the study was to describe pre-pregnancy body mass index (BMI), total gestational weight gain (TGWG), and trimester-specific gestational weight gain (TSGWG) among Asian Indians and examine their association with adverse fetomaternal outcomes (AFMO). Methods: Using a prospective cohort study design, 557 pregnant women were recruited in the first trimester and followed up until delivery. Maternal BMI, TGWG and TSGWG were assessed and categorised according to the World Health Organisation (WHO) Asia Pacific BMI guidelines and the Institute of Medicine (IOM) recommendations, respectively. Maternal clinical characteristics and pregnancy and neonatal outcomes were assessed to predict AFMO. Logistic regression models in univariate and multivariate analysis were performed to estimate the odds ratios (OR) and 95% confidence intervals (CI). Results: The median BMI was 23.5 kg/m2. Moreover, 24.6% were overweight and 31.2% were obese, according to WHO Asia Pacific BMI cut points. The mean TGWG was 10.8 ± 1.9 kg and the mean TSGWG in the first, second and third trimesters were 1.7 ± 0.7 kg, 4.3 ± 1.1 kg and 4.8 ± 1.2 kg, respectively. We found a significant association of BMI, TGWG and TSGWG with various AFMO. Furthermore, excess third-trimester GWG has been demonstrated as a predictor of adverse maternal outcomes like hypertension and gestational diabetes mellitus. Conclusions: Our study reinforces the importance of optimal BMI and TGWG and further emphasises on assessment of TSGWG, which allows for early diagnosis of weight deviations, when prompt interventions can still improve pregnancy outcomes. We also suggest the adoption of BMI categories and GWG recommendations, specific to the socio-demographic characteristics of the population, to optimise the prevention, early diagnosis, and timely management of AFMO.