Prior History Of Diabetes Mellitus Research Articles

External validation of Finnish diabetes risk score (FINDRISC) and Latin American FINDRISC for screening of undiagnosed dysglycemia: Analysis in a Peruvian hospital health care workers sample.

To evaluate the external validity of Finnish diabetes risk score (FINDRISC) and Latin American FINDRISC (LAFINDRISC) for undiagnosed dysglycemia in hospital health care workers. We carried out a cross-sectional study on health workers without a prior history of diabetes mellitus (DM). Undiagnosed dysglycemia (prediabetes or diabetes mellitus) was defined using fasting glucose and two-hour oral glucose tolerance test. LAFINDRISC is an adapted version of FINDRISC with different waist circumference cut-off points. We calculated the area under the receptor operational characteristic curve (AUROC) and explored the best cut-off point. We included 549 participants in the analysis. The frequency of undiagnosed dysglycemia was 17.8%. The AUROC of LAFINDRISC and FINDRISC were 71.5% and 69.2%; p = 0.007, respectively. The optimal cut-off for undiagnosed dysglycemiaaccording to Index Youden was ≥ 11 in LAFINDRISC (Sensitivity: 78.6%; Specificity: 51.7%) and ≥12 in FINDRISC (Sensitivity: 70.4%; Specificity: 53.9%). The discriminative capacity of both questionnaires is good for the diagnosis of dysglycemia in the healthcare personnel of the María Auxiliadora hospital. The LAFINDRISC presented a small statistical difference, nontheless clinically similar, since there was no difference by age or sex. Further studies in the general population are required to validate these results.

SAT116 Utilizing User-centered Design And Usability And Skills Testing For Remote Diabetes Survival Skills Training

Abstract Disclosure: S.J. Freeman: None. B. Radonski: None. L. Lecka: Employee; Self; Doximity. Stock Owner; Self; Doximity. K. Davis: None. G. Prince: None. K. Carthy: None. J.J. Seley: Speaker; Self; Lifescan Diabetes Institute. J. Song: None. J. Lee: None. S.C. Bailey: Consulting Fee; Self; Merck, Lundbeck, Sanofi-Aventis, Pfizer, Inc., Luto, University of Westminster, Gilead. Grant Recipient; Self; Merck, Eli Lilly & Company, Pfizer, Inc., Lundbeck, Gordon and Betty Moore Foundation, National Institutes of Health, Gilead. R. Khorzad: None. D. Gatchell: None. B. Ankenman: None. D.R. Lewis: Grant Recipient; Self; Pfizer, Inc., Spencer Foundation, National Institutes of Health. J. Holl: None. A. Wallia: Consulting Fee; Self; Eli Lilly & Company. Grant Recipient; Self; Novo Nordisk. Research Investigator; Self; UnitedHealth Group, Eli Lilly & Company. Patient-centered approaches for teaching diabetes mellitus (DM) survival skills are essential. Furthermore, in the peri-COVID era, interventions also need to be amenable to remote care delivery. User-Centered design (UCD) including usability testing is a key strategy to optimize adoption and engagement of interventions. We developed a Diabetes Survival Skills Toolkit (website, paper guide, and a physical Kit with simulation supplies) using UCD (> 50 sessions), followed by administration of system usability surveys (SUS) (scored as unacceptable, acceptable, or excellent) and, in a subset, additional skills testing. Skills testing included simulated blood glucose checks and insulin administration, conducted by 2 trained observers. Forty-three participants with no prior history of DM were recruited between 01/2021-07/2022 to independently learn survival skills using different Toolkit components [website only (N=11), Kit + paper guide (N=28), and Kit + website (N=4)]. Purposive sampling for age and highest education level resulted in 33% being ≥ 65 years and 35% having < 4-year degree. Overall, SUS scores were deemed excellent (N=15/43 [35%]) or acceptable (N=20/43 [47%]). Unacceptable scores were noted in 8/43 (19%) [4 website only (all > 4-year degree) and 4 Kit + paper guide (3 of 4 > 65 years, all < 4-year degree)]. Use of the website alone resulted in a higher rate of unacceptable SUS scores (37%) compared to use of the Kit with either the paper guide or website (13%). SUS-score category was not associated with age (82% acceptable/excellent among <45 years, 86% among 45-64 years, and 79% among >=65 years; Fishers’ p=1.00) nor highest education level (80% acceptable/excellent among <4-year degree and 82% among >=4-year degree; Fisher’s p=0.69). Participants who completed skills testing (N= 28 Kit + paper guide, 4 Kit + website), regardless of their SUS score, all correctly demonstrated the ability to inject insulin with simulation supplies. However, 4/32 (13%) (all SUS scores acceptable/excellent) were unable to navigate all steps independently and 9/32 (28%) (2 SUS unacceptable) did not use the recommended instructional pathway. All 4 participants (3 with > age 65 and < 4-year degree) who completed skills testing but had unacceptable SUS scores still correctly demonstrated the ability to measure blood glucose and inject insulin. In conclusion, a Survival Skills Toolkit, resulted in excellent rates of successful survival skills performance when tested with laypersons of diverse ages and education levels. Subjective usability (SUS scores) did differ among users of different Toolkit components; however, they did not align with actual skill performance. Design preferences and usability tests as well as subsequent skills testing are critical to optimally design tools for diabetes survival skills training. Presentation: Saturday, June 17, 2023

Diagnostic Challenge of Adult-onset Type 1 Diabetes Mellitus in a Remote Hospital

Type 1 Diabetes Mellitus (T1DM) is a chronic endocrinological disease due to an autoimmune process. The prevalence of T1DM is 9.5% worldwide, with the incidence of 15 out of 100,000 people, ranging from childhood to 40 years of age. Autoimmunity-related late-onset Diabetes Mellitus (DM) patients could be diagnosed as classic T1DM or latent autoimmune diabetes in adults (LADA). A 30-year-old male patient with unremarkable previous medical history was admitted to the emergency room with dyspnea for the last three days that was worsened six-hour before admission. Physical examinations showed a body Mass Index (BMI) of 18.75 kg/m2, irregular pulse, and Kussmaul breathing. The patient was diagnosed with diabetic ketoacidosis (DKA) on May 23, 2019. He was discharged with subcutaneous insulin pen injections. Two years later, he was readmitted with DKA due to discontinuing his treatment. He stated that the reason for stopping the insulin was because he was tired of injecting it. The patient was hospitalized and was discharged with oral antidiabetic agents to cope with his injection tiredness issue. One week later, the patient complained of dyspnea and was diagnosed with recurrent DKA. He was hospitalized and prescribed subcutaneous insulin. In this kind of situation, a diagnosis of LADA for patients presenting with DKA without prior history of DM in early adulthood needs to be considered. In contrast to the classic T1DM, the need for insulin occurs late in LADA. Affordable and widely available ancillary examinations are needed, including in remote hospitals. Finally, motivational support for patients is as important as the pharmacological treatment since lifelong insulin injections are needed.

Point-of-care glycated hemoglobin a1c testing for the identification of hyperglycemia severity among individuals with dual tuberculosis and diabetes mellitus in Tanzania.

Poor glycemic control during tuberculosis (TB) treatment is challenging, as the optimum treatment strategy remains unclear. We assessed hyperglycemia severity using glycated hemoglobin (HbA1c) test and predictors of severe hyperglycemia at the time of TB diagnosis in three resources-diverse regions in Tanzania. This was a substudy from a large cohort study implemented in three regions of Tanzania. TB individuals with diabetes mellitus (DM) (prior history of DM or newly diagnosed DM) were assessed for hyperglycemic levels using HbA1c test and stratified as mild (<53 mmol/mol), moderate (≥53-<86 mmol/mol), and severe (≥86 mmo/mol). From October 2019 to September 2020, 1344 confirmed TB individuals were screened for DM and 105 (7.8%) individuals had dual TB/DM and were assessed for glycemic levels. Of these, 69 (67.7%) had a prior history of DM and 26 (24.8%) were living with human immunodeficiency virus. Their mean age was 49.0 (±15.0) years and 56.2% were male. The majority (77.1%) had pulmonary TB, and 96.2% were newly diagnosed TB individuals. HbA1c test identified 41(39.0%), 37 (35.2%), and 27 (25.7%) individuals with severe, moderate, and mild the hyperglycaemia respectively. Female sex (odds ratio [OR]: 3.55, 95% confidence interval [CI]: 1.06-11.92, P = 0.040) and previous history of DM (OR: 3.71, 95% CI: 1.33-10.33, P = 0.013) were independent risk factors for severe hyperglycemic at the time of TB diagnosis. By integrating early HbA1c testing, a substantial proportion of individuals with severe hyperglycemia were identified. HbA1c testing can be recommended to identify and triage patients requiring personalized intensified DM management in resource-limited programmatic settings.

Glycemic Control Variations In Covid-19 Associated Mucormycosis”

Background: Mucormycosis is opportunistic invasive fungal infection characterised by angioivasion, thrombosis and necrosis of the tissues. Diabetes mellitus being the commonest immunocompromised state predisposing to mucormycosis in India, a study about glycemic control in CAM (covid-19 associated mucormycosis) patients and the severity of mucormycosis was necessary so as to reduce the morbidity and mortality in CAM patients. Methods: A retrospective descriptive study was conducted between May 2021 and July 2021 at Bowring &amp; Lady Curzon hospital. 315 patients with post-covid ROCM (rhino-orbito-cerebral mucormycosis) were included in the study. Glycemic control of the patients was monitored with FBS, PPBS, HBA1C values.The extent and severity of CAM was studied in patients with good and poor glycemic control.. Results: 243 (77.14%) patients were male and 72 (22.86%) were female. 296 (93.97% )patients had prior history of diabetes mellitus and 19 (6.03%) patients had newly detected diabetes mellitus. 275(87.30%) patients had poor glycemic control. 17 (6.18%) patients out of 275 presented with diabetic ketoacidosis (DKA). 40 (12.70%) patients had good glycemic control. Conclusions: Diabetes mellitus has emerged as important risk factor associated with development of mucormycosis. In covid-19, poorly controlled diabetes, steroid induced hyperglycemia, covid induced insulin resistance act as fertile land for the development of mucormycosis. Hence monitoring glycemic status, judicious use of steroids, control of sugars may help in reducing the severity or occurance of mucormycosis. Keywords: Mucormycosis, Diabetes mellitus, Covid-19 associated mucormycosis, Hyperglycemia.

ODP623 Life Threatening Diabetic Ketoacidosis as First Presentation of Tacrolimus-Induced Diabetes Mellitus.

Abstract Background New-onset diabetes after transplantation (NODAT) is a serious complication after a solid organ transplant. NODAT occurs in 2% to 53% of all solid organ transplant recipients.1 Tacrolimus is an immunosuppressive agent associated with diabetogenic potential which predominantly is a result of suppression of insulin secretion from pancreatic beta cells. Diabetic ketoacidosis as the first presentation of new onset tacrolimus induced diabetes is rare. We report a case of diabetic ketoacidosis (DKA) in a patient without prior history of diabetes mellitus and receiving tacrolimus as part of immunosuppressive regime post-renal transplant. Clinical Case A 62-year-old female with past medical history of autosomal polycystic kidney disease status-post deceased donor renal transplant and hypertension presented with weakness and fatigue. She had undergone transplant 8 months prior to this presentation and her immunosuppressive regime consisted of mycophenolate mofetil and tacrolimus. The patient was encephalopathic on arrival with normal vitals. Laboratory evaluation was significant for blood glucose of 673, bicarbonate of &amp;lt;10, anion gap of 24, Beta-hydroxybutyrate &amp;gt;8 and a pH of 7.19 on arterial blood gas analysis thus confirming diagnosis of diabetic ketoacidosis (DKA). Tacrolimus level was elevated at 35.7. Intravenous fluids and insulin were initiated with resolution of symptoms and DKA. She was transitioned to a basal-bolus insulin regimen. Further labs revealed Hemoglobin A1C of 11.6% (no previous value), negative insulin antibodies and glutamic acid decarboxylase antibody, and a low C-peptide level at 0.47 (when blood glucose was 150mg/dl). Her tacrolimus dose was adjusted, and she was discharged on a basal-bolus insulin regimen. On follow up, the patient had lower insulin requirements with improvement in C-peptide level to 1.8, thus, indicating beta cell dysfunction in setting of supratherapeutic tacrolimus levels. Conclusion Tacrolimus remains the preferred immunosuppressive agent after kidney transplantation given lower incidence of acute rejections and better tolerance. However, due to its toxic effects on pancreatic beta cells it is imperative blood sugar levels should be routinely monitored in patients on tacrolimus. Appropriate monitoring can lead to timely diagnosis and successful outcomes. Further studies are required to investigate risks factors associated with tacrolimus induced DKA.

IMMUNE CHECKPOINT INHIBITOR-INDUCED DIABETIC KETOACIDOSIS: A RARE SIDE EFFECT

IMMUNE CHECKPOINT INHIBITOR-INDUCED DIABETIC KETOACIDOSIS: A RARE SIDE EFFECT

Design, recruitment, and baseline characteristics of the EMPA-KIDNEY trial.

ABSTRACTBackgroundThe effects of the sodium-glucose co-transporter 2 inhibitor empagliflozin on renal and cardiovascular disease have not been tested in a dedicated population of people with chronic kidney disease (CKD).MethodsThe EMPA-KIDNEY trial is an international randomized, double-blind, placebo-controlled trial assessing whether empagliflozin 10 mg daily decreases the risk of kidney disease progression or cardiovascular death in people with CKD. People with or without diabetes mellitus (DM) were eligible provided they had an estimated glomerular filtration rate (eGFR) ≥20 but <45 mL/min/1.73 m2 or an eGFR ≥45 but <90 mL/min/1.73 m2 with a urinary albumin:creatinine ratio (uACR) ≥200 mg/g. The trial design is streamlined, as extra work for collaborating sites is kept to a minimum and only essential information is collected.ResultsBetween 15 May 2019 and 16 April 2021, 6609 people from eight countries in Europe, North America and East Asia were randomized. The mean age at randomization was 63.8 years [standard deviation (SD) 13.9)], 2192 (33%) were female and 3570 (54%) had no prior history of DM. The mean eGFR was 37.5 mL/min/1.73 m2 (SD 14.8), including 5185 (78%) with an eGFR <45 mL/min/1.73 m2. The median uACR was 412 mg/g) (quartile 1–quartile 3 94–1190), with a uACR <300 mg/g in 3194 (48%). The causes of kidney disease included diabetic kidney disease [n = 2057 (31%)], glomerular disease [n = 1669 (25%)], hypertensive/renovascular disease [n = 1445 (22%)], other [n = 808 (12%)] and unknown causes [n = 630 (10%)].ConclusionsEMPA-KIDNEY will evaluate the efficacy and safety of empagliflozin in a widely generalizable population of people with CKD at risk of kidney disease progression. Results are anticipated in 2022.

Co-Relation of Steriods in Diabetic and COVID-19 Patients

An unusual rise in blood glucose linked with the use of glucocorticoids in a patient with or without a prior history of diabetes mellitus is referred to as steroid-induced diabetes mellitus. The term steroid refers to a group of chemicals that have varied physiological effects. Hydrocortisone are a class of hormones that comprises both lab-made and naturally occurring hormones. Steroids are naturally occurring hormones in the human body. Corticosteroids have a wide spectrum of effects, from solely glucocorticoid to solely mineralocorticoid, and steroid compounds are chosen based on their suitability for a particular therapy. A drug may have anti-inflammatory resources, it could also have mineralocorticoid action, which lowers blood pressure. Steroids are drugs that have been used extensively in a variety of conditions. Glucocorticoids, despite being frequently recommended for their anti-inflammatory and immunosuppressive characteristics, have a number of side effects, with hyperglycemia being one of the most common and representative. In diabetic individuals, corticosteroids are generally contraindicated due to the danger of altering glucose control and resulting in severe decompensation. However, if given early and in a well-controlled regimen, corticosteroid medication can be useful in some patients. With good knowledge of the pharmacokinetics of the glucocorticoid utilized, glucose disequilibrium after withdrawal can be predicted.

The association of new-onset diabetes mellitus and medical therapy for benign prostatic hyperplasia: A population-based study.

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms are highly prevalent in the aging male. Similarly, the prevalence of metabolic syndrome is increasing worldwide, with mounting evidence that these two common conditions share more than age as a predisposing factor. The objective of this study was to determine if medical management of BPH is associated with an increased risk of new-onset diabetes mellitus (DM) in routine care. This population-based, retrospective cohort study expands on a parent study of linked administrative databases identifying patients diagnosed and treated for BPH between 2005 and 2015. The primary outcome of this secondary analysis was a new diagnosis of DM after the index date of BPH diagnosis. Covariates included age, dyslipidemia, hypertension, and vascular diseases. A Cox proportional hazards regression model was used for inferential statistical analysis. A total 129 223 men were identified with a BPH diagnosis and no prior history of DM. Of those men, 6390 (5%) were exposed to 5-alpha-reductase inhibitor (5-ARI), 39 592 (31%) exposed to alpha-blocker (AB), and 30 545 (24%) exposed to combination therapy. Compared to those men with no BPH medication use, those exposed to drugs had an increased risk of new DM. Men treated with combination therapy of 5-ARI and AB (hazard ratio [HR] 1.30, 95% confidence interval [CI] 1.25-1.35), 5-ARI monotherapy (HR 1.25, 95% CI 1.17-1.34), or AB monotherapy (HR 1.17, 95% CI 1.13-1.22) all were at higher risk of new DM diagnosis after adjusting for important covariates. When calculating the risk of a new diabetes diagnosis measured from the start of drug exposure, men treated with 5-ARIs had an increased risk of DM compared to AB monotherapy as the reference, with HR 1.12 (95% CI 1.03-1.21) for 5-ARI monotherapy and HR 1.20 (95% CI 1.14-1.25) for combination therapy. In this large, long-term, retrospective study of men with a BPH diagnosis in routine practice, the risk of a new diagnosis of DM was greater in patients receiving medical management compared to controls. This modest but significant increased risk was highest in men treated with any 5-ARIs, in combination as well as monotherapy, compared to the ABs.

Immunotherapy-Related Autoimmune Diabetes Mellitus and Exogenous Insulin Antibody Syndrome in a Patient With Metastatic Oral Squamous Cell Carcinoma

Introduction: Exogenous insulin antibody syndrome (EIAS) is a rare condition characterized by wide glycemic excursions and recurrent hypoglycemia in the presence of high insulin antibody titers. It has been described in diabetic patients treated with exogenous insulin. Programmed death ligand 1 (PD-L1) inhibitors are known to cause autoimmune diabetes mellitus, but PD-L1-related EIAS has not yet been reported to our best knowledge. Case Description: A 63 years old Caucasian man with history of recurrent oral squamous cell cancer presented to emergency room with polyuria, polydipsia, nausea, and vomiting 3 months after initiation of immunotherapy (Durvalumab and cetuximab). He had no prior history of diabetes mellitus or hypoglycemia. He was admitted to hospital for management of diabetic ketoacidosis (Anion gap of 24 mEq/L, venous blood glucose of 805 mg/dL, Venous PH of 7.12, large urine ketone, A1C of 8.9%). After a brief hospital stay, the patient was discharged home on insulin glargine and metformin. His immunotherapy was resumed after hospital discharge. When the patient was seen by Endocrinologist in the clinic, metformin was discontinued and prandial insulin lispro was added. This basal-bolus insulin regimen improved his glycemic control initially. However, without significant changes in his lifestyle or medical condition, he developed worsening postprandial hyperglycemia and recurrent fasting hypoglycemia. Up-titration of his mealtime insulin did not lower postprandial hyperglycemia but possibly worsened fasting hypoglycemia. EIAS was suspected after reviewing his continuous glucose monitoring data. Further work up at this point revealed mildly elevated glutamic acid decarboxylase antibodies (5.9 units/mL, normal range 0.5 - 5.0) and markedly elevated insulin antibody level (77.0 µU/mL, normal range <5). His blood C-peptide was undetectable when his venous blood glucose was 252 mg/dl. In addition, his total insulin level (198 uU/mL) was much higher than his free insulin level (38 uU/mL) following an insulin lispro injection. The patient was diagnosed with EIAS. Switching insulin lispro to insulin aspart while he was on a different immunotherapy medication (Pembrolizumab) immediately reduced his average blood glucose and reduced his total daily insulin dosage by more than 50%. This improvement in glycemic control with insulin aspart only lasted for about 1 week. Unfortunately, the patient’s squamous cancer progressed on immunotherapy. He was referred to hospice care and passed away. Conclusion: Evaluation for EIAS would be reasonable in insulin-treated diabetic patients who develop wide glucose excursions and unexplained fasting hypoglycemia while on immunotherapy.

New-Onset Diabetic Ketoacidosis Secondary to Nivolumab Therapy in a Patient with Primary Central Nervous System Lymphoma

Introduction: Inhibitors of programmed cell death receptor (PD-1) and its ligand (PD-L1), such as nivolumab and pembrolizumab, confer anti-autoimmune activities and are therefore approved for anti-cancer therapy. Their mode of action removes autoimmunity checkpoints, thus increasing the risk of immune-related adverse events.&#x0D; Case Presentation: This report describes a clinical case of life-threatening diabetic ketoacidosis (DKA) in a patient after long-term nivolumab administration to treat primary central nervous system lymphoma (PCNSL). The patient presented to the emergency department (ED) with symptoms of fatigue, along with nausea and vomiting for two days; laboratory testing revealed significant hyperglycemia (glucose 673 mg/dL), elevated anion gap (&gt;27), metabolic acidosis, ketonemia, glucosuria and ketonuria, findings of which were consistent with DKA. Given no personal history of diabetes mellitus or other autoimmune conditions and additional tests ruling out alternative causes, the patient was suspected of having newly-onset DKA secondary to nivolumab treatment.&#x0D; Management &amp; Outcome: The patient was treated with fluids, electrolytes replenishments and insulin drip, which closed the anion gap and normalized electrolytes. She was transitioned to subcutaneous insulin. The patient recovered well and was discharged on Metformin and longacting insulin, with close follow-up with endocrinology and oncology.&#x0D; Discussion: Autoimmune endocrinopathies induced by checkpoint inhibitors for cancer treatment have been reported in the past. Newly-onset hyperglycemia and DKA are common autoimmunemediated side effects of checkpoint inhibitor uses in patients without prior history of diabetes mellitus. Clinicians should be aware to prevent this potentially life-threatening condition.

Impact of Raised Blood Glucose Level on In-Hospital Outcome of Thrombolysed Patients with Acute Myocardial Infarction

Background: Diabetes mellitus (DM) is an established major cardiovascular risk factor associated with increased prevalence of coronary artery disease (CAD). Patients with diabetes often have numerous concomitant cardiac risk factors with a higher incidence of acute myocardial infarction (AMI) and congestive heart failure (CHF). Patients either with or without a prior history of DM may present with hyperglycemia during AMI. We analysed our population to determine whether admission hyperglycemia was a strong risk factor for in-hospital mortality and morbidity in patients with AMI and may be even stronger than a previous history of diabetes.In-hospital death risk of AMI patients without DM was about 2 to 4 times higher in patients with hyperglycemia than in those without hyperglycemia.&#x0D; Methods: This Prospective observational study was carried out at the National Institute of Cardiovascular Diseases (NICVD), Dhaka. A total number of 200 STsegment elevation AMI patients were enrolled in this study as per inclusion and exclusion criteria. They were subdivided on the basis of admission blood glucose into two groups. Group-1A and 2A were 50 patients with blood glucose &lt;200mg/dl (&lt;11.1mmol/l) and Group-1B and 2B were 50 patients with blood glucose ≥200mg/dl (11.1 ≥mmol/l). The numerical data obtained from the study were analyzed and significance of differences were estimated by using statistical methods. Computer based SPSS (Statistical Package for Social Science) were used.&#x0D; Results: In the present study mean age of the male and female were 56.10±11.86 and 57.83±13.74 years, p&gt;0.05%. There was no significant difference regarding risk factors and smoking was higher in both group. Regarding inhospital adverse outcome, death was significantly higher in hyperglycemic non diabetic group (p&lt;0.0001). It was two times (56%) higher than diabetic hyperglycemic (28%) group.Cardiogenic shock (66%) and CHF (56%) were also more common in hyperglycemic non diabetic group. Lowest patients (8%) died of AMI without DM with random blood glucose &lt;11.1 mmol/l (controlled). On the other hand highest improvement was in the controlled group (p&lt;0.0001).Multivariate analysis showed Diabetic status with normal blood sugar was a predictor of adverse outcome; but patients with hyperglycemia and no history of diabetes had a worse outcome and were independently associated with significant risk of in-hospital mortality. Age group &gt;65 years and Male sex were also associated with significant in-hospital mortality.&#x0D; Conclusion: Independent of diabetic status, the occurrence of hyperglycemia during AMI is associated with a subpopulation of patients at particularly high risk for an adverse clinical outcome. Even with the highly efficacious treatment strategies currently available, persons presenting with AMI and hyperglycemia are at increased risk for cardiogenic shock and CHF or death in hospital.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 14-19

SAT-667 Partial Beta-Cell Destruction: An Atypical Case of Immune Checkpoint Inhibitor Diabetes Mellitus

Background: Autoimmune diabetes mellitus (CPI-DM) caused by immune checkpoint inhibitors (CPIs) is rare- occurring in approximately one percent of patients exposed to this form of cancer immunotherapy. Typically, this immune related adverse event occurs after treatment with PD-1/PD-L1 inhibitors. It is characterized by abrupt insulinopenia leading to acute hyperglycemia. Beta cell autoantibodies are positive in approximately half the cases. DKA is common at the time of diagnosis. Recovery of beta cell function has been reported in only two case reports. In one case, spontaneous resolution occurred following cessation of CPI therapy and in the other the patient was treated with infliximab for concurrent inflammatory arthritis prior to resolution of CPI-DM. Clinical Case: A 50-year-old woman was started on adjuvant pembrolizumab for stage IIIC melanoma following surgery. She had no prior history of diabetes mellitus, thyroid disease, or other autoimmune disease. Pre-infusion random blood glucoses (RBG) were 84 - 105 mg/dL. After 36 weeks, she developed hypothyroidism (TSH 17.5 (0.5-4.1 mIU/L), FT4 6 (10-18 ug/dL)) and started levothyroxine. Pembrolizumab was continued. For nine weeks following her diagnosis with CPI- hypothyroidism, her pre-infusion RBG ranged from 102-133. At 45 weeks (15 cycles) after initiating pembrolizumab, her RBG was 260. She was not on glucocorticoids and had no other signs of inflammation or stress. Pembrolizumab was continued. Just prior to her 17th cycle, 48 weeks after initiating adjuvant pembrolizumab, her RBG was 482 with a normal anion gap and HCO3, and her A1c was 8.9%. Her last dose of pembrolizumab was held. She started metformin and liraglutide. In just three weeks, a random c-peptide was inadequate at 1.7 (0.8-3.5 ng/mL) with a recent RBG of 220 and A1c of 10.3%, showing the acuity and extremity of her hyperglycemia. Over the course of the year, she has achieved excellent glucose control (A1c 6.3-7.1) on this regimen with preservation of insulin production (c-peptides 1.4-1.8 with matched RBG 92-129). She never required insulin. Her beta cell autoantibodies are negative. Clinical Lessons: This is a case of CPI-DM in which the patient did not have complete loss of beta-cell function. The acuity of her hyperglycemia is not consistent with new onset type 2 diabetes. At diagnosis, her c-peptide was inadequate suggesting insufficient insulin production rather than insulin resistance. Therefore, her hyperglycemia is more consistent with CPI-DM than type 2 diabetes. Atypically, she did not progress to fulminant beta cell failure, which could have been due to cessation of pembrolizumab (which is not unique to this case), initiation of liraglutide and metformin, or other unknown immunologic responses that inhibited full beta cell loss. This case raises the possibility of preventing fully insulin dependent CPI-DM if hyperglycemia is caught and treated early.

Short-term exposure to air pollution and incidence of stroke in the Women's Health Initiative

BackgroundEvidence of the association between daily variation in air pollution and risk of stroke is inconsistent, potentially due to the heterogeneity in stroke etiology. ObjectivesTo estimate the associations between daily variation in ambient air pollution and risk of stroke and its subtypes among participants of the Women's Health Initiative, a large prospective cohort study in the United States. MethodsWe used national-scale, log-normal ordinary kriging models to estimate daily concentrations of fine particulate matter (PM2.5), respirable particulate matter (PM10), nitrogen dioxide (NO2), nitrogen oxides (NOx), sulphur dioxide, and ozone at participant addresses. Stroke was adjudicated by trained neurologists and classified as ischemic or hemorrhagic. Ischemic strokes were further classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification. We used a time-stratified case-crossover approach to estimate the odds ratio (OR) of the risk of stroke associated with an interquartile range (IQR) increase in concentrations of each air pollutant. We performed stratified analysis to examine whether associations varied across subgroups defined by age at stroke onset, US census region, smoking status, body mass index, and prior history of diabetes mellitus, hypertension, heart or circulation problems, or arterial fibrillation at enrollment. ResultsAmong 5417 confirmed strokes between 1993 and 2012, 4300 (79.4%) were classified as ischemic and 924 (17.1%) as hemorrhagic. No association was observed between day-to-day variation in any pollutant and risk of total stroke, ischemic stroke, or specific etiologies of ischemic stroke. We observed a positive association between risk of hemorrhagic stroke and NO2 and NOx in the 3 days prior to stroke with OR of 1.24 (95% CI: 1.01, 1.52) and 1.18 (95% CI: 1.03, 1.34) per IQR increase, respectively. The observed associations with hemorrhagic stroke were more pronounced among non-obese participants. ConclusionsIn this large cohort of post-menopausal US women, daily NO2 and NOx were associated with higher risk of hemorrhagic stroke, but ambient levels of four other air pollutants were not associated with higher risk of total stroke, ischemic stroke, or ischemic stroke subtypes.

English

Glucocorticoid-induced diabetes mellitus (GIDM) is an abnormal increase in blood glucose associated with the use of glucocorticoids in a patient with or without a prior history of diabetes mellitus. This is a common and potentially harmful problem in clinical practice, affecting almost all medical specialties, but is often diffi&not;cult to detect in clinical settings.&nbsp; The objective of this study was to determine effect of Parkia biglobosa extract on open wound healing in dexamethasone induced hyperglycaemia. Effect of&nbsp; three different doses of P. biglobosa extract (25, 50 and 100 mg/kg body wt.) for 14 consecutive days&nbsp; on open skin wound healing before and after&nbsp; dexamethasone-induced hyperglycaemia was investigated; histological assessment was also conducted on the fourteenth day. The three different doses of P. biglobosa extract decreased the serum glucose concentration in pre and post-treatment dexamethasone-induced hyperglycaemic animals; the percentage reduction was greater in the 50 and 100 mg/kg of P. biglobosa-pretreated groups (14.9 and 19.21%, respectively) as compared to that of ketoconazole, where it was only 16.5%. In the post treatment groups, the percentage reduction was greater in 100 mg/kg of P. biglobosa (17.7%) as compared to that of ketoconazole, where it was only 16.6%. Histological evaluation showed that the pretreated group of animals had higher performance scores on the grading scale and improved healing when compared with the post-treated groups. There was a demonstrable reduction in the wound healing process in the pre-treatment group that was dosed dependent. Key words: Parkia biglobosa, open skin wound healing, dexamethasone-induced hyperglycaemia, histological assessment. &nbsp

SUN-167 Quetiapine-Induced Hypertriglyceridemia and Hyperglycemia Presenting as Simultaneous Diabetic Ketoacidosis and Acute Pancreatitis

Background: Quetiapine-induced metabolic emergencies such as diabetic ketoacidosis (DKA) and acute pancreatitis (AP) are rare. We describe a case of new-onset hypertriglyceridemia (HTG) and diabetes mellitus (DM) following the initiation of quetiapine, presenting as concurrent new-onset DKA and AP. Clinical Case: A 34 year-old male with bipolar disorder and schizophrenia presented with three days of epigastric pain, nausea, and vomiting. He had no prior history of DM or dyslipidemia (DLD). He reported long-standing use of divalproex, benztropine, and haloperidol. He had started quetiapine three months prior, at which time glycosylated hemoglobin A1c (HgbA1c) was 5.7% and non-fasting triglyceride (TG) level was 266 (range 30-150 mg/dL). He was a smoker, but denied alcohol or drug use. On admission, he was hypertensive, tachycardic, and febrile with significant abdominal pain. His blood glucose was 522 (range 55-110 mg/dL) with an anion gap of 27 (range 5-17), venous pH of 7.18 (range 7.33-7.43), bicarbonate of 7 (range 23-31 mEq/L), and serum creatinine of 1.8 (0.6-1.4 mg/dL). He also had an elevated serum lipase of 317 (range 5-55 U/L), TG of 2436 (range 30-150 mg/dL), and computed tomography confirmed peri-pancreatic edema consistent with AP. Thyroid function tests were normal. Abdominal ultrasound was negative for cholelithiasis. He was treated with aggressive intravenous (IV) hydration and IV insulin, and later transitioned to subcutaneous (SQ) insulin after resolution of DKA. Quetiapine was stopped and he was discharged on haloperidol, benztropine, fenofibrate, and SQ insulin. Due to improving BG levels, insulin was gradually tapered over the next few weeks and subsequently discontinued. HgbA1c obtained three months later was 5.7% (off insulin) and fasting TG level was 212 mg/dL. Discussion: Second generation antipsychotics (SGAs), particularly olanzapine and clozapine, are known to cause metabolic abnormalities such as weight gain, hyperglycemia, and hyperlipidemia. Although quetiapine is described to have low risk for development of diabetes or lipid abnormalities, it can cause life-threatening complications like DKA and AP. While DKA has been reported in many case series, AP is exceedingly rare. There are fewer than ten reported cases with or without HTG following quetiapine use, usually within the first year of drug initiation. Since many of these patients do not have pre-existing DLD or DM, it is important for providers and patients to be aware of the risk of developing these life-threatening complications, even with a relatively safe SGA. Current guidelines recognize the importance of laboratory monitoring for early detection of metabolic disturbances in patients taking SGAs; however, recommendations regarding frequency of monitoring remain variable. Updated surveillance parameters are needed to facilitate the prevention of such metabolic emergencies.

Prevalence, Risk Factors, and Fetomaternal Outcomes of Gestational Diabetes Mellitus in Kuwait: A Cross-Sectional Study.

Objective Gestational diabetes mellitus (GDM) is a growing global public health problem that can have short- and long-term health consequences for the mother and the child. Despite its criticalness, many countries still do not have the epidemiological data which could guide them in responding to the problem. Due to the lack of knowledge on GDM and the fact that diabetes and obesity are high in Kuwait, this study sought to estimate the prevalence of GDM and determine its risk factors and outcomes. Methods This cross-sectional study enrolled 947 mothers living in Kuwait, who had given birth within the previous four years. Participants were recruited from primary health care clinics and public hospitals. GDM status was self-reported by the mother. Associations between exposures and outcomes were evaluated using logistic regression, and adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated. Results Of the 868 mothers with no prior history of diabetes mellitus, 109 (12.6%, 95% CI: 10.4, 14.8) reported having been given a GDM diagnosis during their last pregnancy. The prevalence of GDM increased with maternal age and prepregnancy body mass index. GDM was positively associated with caesarean section delivery (aOR = 1.76, 95% CI: 1.17, 2.66) and fetal macrosomia (aOR = 2.36, 95% CI: 1.14, 4.89). Conclusion GDM is prevalent in Kuwait and is associated with poor maternal, fetal, and neonatal outcomes. To date, GDM has received little attention, and there is a need for more research to identify and respond to individual and public health implications of GDM in Kuwait.

Abstract TP145: Admission Hyperglycemia Predicts Poor Cerebral Collateral Flow in Acute Ischemic Stroke

Introduction: Poor leptomeningeal collateral flow is related to worse neurological outcome in acute ischemic stroke. The increased release of stress hormones during the first hours of acute stroke leads to inhibition of insulin secretion and increase insulin resistance, thus inducing stress hyperglycemia, which is often evident on blood glucose levels at admission. While admission hyperglycemia, independent of diabetes mellitus (DM) is associated with poor clinical outcome in ischemic stroke, studies on its effect on collateral circulation after acute cerebral embolism are largely inconclusive. Methods: We identified a consecutive series of patients aged 18 years and older from 2008 to 2018 with acute embolic large vessel stroke confirmed on CT angiography (CTA) using an institutional database. Individual CTAs were over-read, and collateral scores of the affected hemisphere were calculated using a modification of the Tan scale (0-4), by two trained readers. We reviewed the electronic medical records for presenting NIHSS, admission glucose and HbA1C levels, and prior history of DM. Spearman’s ρ, odds ratios (OR), and their 95% confidence intervals (CI) were analyzed. All tests were considered significant when P&lt;0.05. Results: Of the 405 patients identified through the database (mean age 70 years [range, 55-85], 45% [183/405] women), 35% (142/405) had a prior history of DM. Mean admission glucose was 134±51 mg/dL, and median NIHSS at presentation was 17. Blood glucose level at admission was negatively correlated with collateral scores (ρ= -0.23, P=0.008). Specifically, glucose levels above 120 mg/dL were significantly associated (OR 1.68 CI 1.13-2.5) with poor collateral scores (≤1). However, collateral scores exhibited no statistically significant relationship with HbA1c (ρ=-0.08, P=0.15) or prior history of DM (P=0.73). Conclusions: Patients with higher admission glucose levels have poor collateral scores, while HbA1c and prior DM do not have a similar effect on collateral flow. Our results suggest that poor collateral flow may explain adverse outcomes associated with hyperglycemia in acute ischemic stroke. Determining if there is a benefit of aggressive glycemic control within the first few hours of embolic stroke warrants further study.

Increased Risk of Diabetes Mellitus Among Adult Survivors of B-Cell Non-Hodgkin Lymphoma

▪IntroductionImprovements in multi-modal therapies have increased survival rates for older adults diagnosed with B-cell Non-Hodgkin Lymphoma (B-NHL). Despite this success, B-NHL survivors are at an increased risk for developing long-term and late complications of these therapies thereby compromising survival. Several studies have reported an increased risk in diabetes mellitus (DM) among long-term survivors of Hodgkin lymphoma and pediatric cancers. However, there are limited data on the risk of DM and its risk factors in older adults following treatment for B-NHL. Using data from the Utah Population Database, we evaluated the association between treatment for B-NHL and DM risk and furthermore compared this risk to a matched Utah general population. We hypothesized that the risk of DM among B-NHL survivors would be significantly increased compared to the general population.MethodsAdult (age >18 years at diagnosis) survivors of primary B-NHL living in Utah at the time of diagnosis between 1997-2013, without a previous diagnosis of DM, and matched (1:4) to individuals without a prior history of DM from the Utah general population for birth year, birth state, and sex were included. New DM diagnoses were identified for all-time, 0-1, 1-5, and 5-10 years following a diagnosis of B-NHL. Adjusting for sex, race, baseline body mass index (BMI), and Charlson Comorbidity Index (CCI) scores, multivariate Cox proportional hazard analysis was performed to estimate the adjusted hazard ratio (aHR) of DM in B-NHL survivors compared with that in matched non-B-NHL individuals. Risk factors for DM were evaluated, including age at diagnosis, race, sex, BMI at baseline, family history of DM, cancer stage at diagnosis, and treatment modality. The risk of developing DM during all-time, 0 to 1, 1 to 5, and 5 to 10 years follow-up after adjusting for demographic variables was analyzed by age (< 40, 40-65, and >65 years) at diagnosis of B-NHL.ResultsThe study population included 3,970 B-NHL survivors and 19,821 matched individuals from the general population. At the time of diagnosis, the majority of B-NHL patients were age 60 or greater (61.4%), had diffuse large B-cell lymphoma (46%) or follicular lymphoma (26.4%), distant cancer stage (50.1%), and received chemotherapy (27.5%). DM was diagnosed in 897 (22.6%) B-NHL survivors and 3,253 (16.4%) non-B-NHL adults. The majority in both groups were male (B-NHL: 55.5%; controls: 55.5%), white (B-NHL: 97.4%; controls: 93.8%), overweight [BMI 25-29.9 kg/m2 (B-NHL: 40.7%; controls: 40.6%)] or obese [BMI ≥30 kg/m2 (B-NHL: 21.8%; controls: 18.5%)]. The risk of developing DM among B-NHL survivors compared to the control group was significantly increased over all time (HR, 1.34; 95% CI 1.24 - 1.44) and the 0 to 1 year follow-up period (HR, 1.28; 95% CI 1.15 - 1.43)(Table 1). Multivariable analysis for DM risk showed that age 40-65 years and BMI ≥25 were factors independently associated with developing DM at all-time, 0 to 1, 1 to 5, and 5 to 10 years after diagnosis of B-NHL. Male sex and a family history of DM were significantly associated with development of DM during all time, 1 to 5, and 5 to 10 year follow-up periods. Distant cancer stage at diagnosis was a significant risk factor for DM at all time and 1 to 5 years while receipt of chemotherapy only or chemotherapy with radiation were significantly associated with development of DM at 5 to 10 years after diagnosis of B-NHL (estimated aHR and CIs are shown in Table 2). There was no significant association between race and the development of DM.ConclusionAdult survivors of B-NHL have an overall significantly higher risk of developing DM in the first year and over all time following a diagnosis of B-NHL compared to the general population. Age 40 to 65 years and BMI ≥25 were significant risk factors for DM across all follow-up periods while treatment with chemotherapy only or chemotherapy with radiation significantly increased the risk of DM 5-10 years after diagnosis of B-NHL. Race did not appear to be a risk factor for DM but this result may reflect the homogeneity of our study population. These findings contribute important information to the existing literature regarding the risk of developing DM in adult B-NHL survivors and provide foundation for the development of screening and management guidelines for DM in the B-NHL survivor population. DisclosuresNo relevant conflicts of interest to declare.