Abstract Diabetic ketoacidosis (DKA) can be life threatening if not recognized and treated promptly. DKA is characterized by hyperglycemia, acidosis, ketosis and elevated anion gap. The presence of these metabolic derangements is essential to make the diagnosis. The use of cannabis has been associated with atypical acid-base profile in DKA which may contribute to confusion in diagnosis and treatment. Case A 20-year-old man with type 1 diabetes since age 10 presented to the emergency department with 4 days of nausea, vomiting and elevated blood glucose (BG). Emesis occurred up to 6 times daily and started 2 days prior to hyperglycemia. He was unable to correct BG with rapid acting insulin. Moderate urine ketones were present. He denied symptoms of diarrhea, fever, sore throat, runny nose or cough and reported adherence to insulin regimen. Physical exam was remarkable for dry mucous membranes and mild epigastric tenderness. Lab evaluation showed BG of 268 (70-110mg/dL), sodium 133 (135-145 mmol/L), potassium 3.6 (3.5- 5.1 mmol/L), chloride 95 (98-107 mmol/L), bicarbonate 22 (22-32 mmol/L), creatinine 0.8 (0.6–1.2 mg/dL), Anion gap 16, beta-hydroxybutyrate 3.38 (<0.27 mmol/L). He had normal white blood cell count and infectious work up was unremarkable. The patient was started on continuous IV fluids and was managed with intermittent subcutaneous rapid acting insulin in addition to basal insulin. After anion gap closure he was transitioned to his home doses of insulin. Prior to discharge, the patient discretely asked about the effects of smoking marijuana on BG and subsequently disclosed he had increased his use of marijuana recently. Discussion Diabetic keto-alkalosis may present as a result of recurrent vomiting that leads to gastric acid loss. Cannabis use has been linked to an increased risk of diabetic keto-alkalosis. The underlying mechanism is hypothesized to be related to cannabis effects on the stomach causing delayed gastric emptying and leading to cyclic nausea and vomiting. One study conducted to investigate acid-base parameters seen in atypical DKA in Type 1 Diabetes referred to this as "Hyperglycemic Ketosis due to Cannabis Hyperemesis Syndrome" (HK-CHS) recommending obtaining urine drug screen in patients with atypical DKA 1 . Attention should be drawn to this phenomenon as cannabis use has grown with its legalization in many states. Individuals with T1D presenting with ketosis but normal or elevated pH and/or serum bicarbonate may confuse clinicians and delay proper diagnosis. When the patient does not disclose cannabis use voluntarily, taking a thorough social history is critical to making the correct diagnosis. Reference: 1. Akturk HK, Snell-Bergeon J, Kinney GL, Champakanath A, Monte A, Shah VN. Differentiating diabetic ketoacidosis and hyperglycemic ketosis due to cannabis hyperemesis syndrome in adults with type 1 diabetes. Diabetes Care 2021 December 8,: dc211730 Presentation: No date and time listed
OBJECTIVE We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals. RESEARCH DESIGN AND METHODS We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients’ relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2–51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial–Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables. RESULTS Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06–1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47–3.51; P = 0.0002). CONCLUSIONS The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.
We combined multimodal imaging (bioluminescence, X-ray computed tomography, and PET), tomographic reconstruction of bioluminescent sources, and two unique, complementary models to evaluate three previously synthesized PET radiotracers thought to target pancreatic beta cells. The three radiotracers {[ 18 F]fluoropropyl-(+)-dihydrotetrabenazine ([ 18 F]FP-DTBZ), [ 18 F](+)-2-oxiranyl-3-isobutyl-9-(3-fluoropropoxy)-10-methoxy-2,3,4,6,7,11b-hexahydro-1H-pyrido[2,1-a]isoquinoline ( 18 F-AV-266), and (2 S ,3 R ,11b R )-9-(3-fluoropropoxy)-2-(hydroxymethyl)-3-isobutyl-10-methoxy-2,3,4,6,7,11b-hexahydro-1 H -pyrido[2,1- a ]isoquinolin-2-ol ( 18 F-AV-300)} bind vesicular monoamine transporter 2. Tomographic reconstruction of the bioluminescent signal in mice expressing luciferase only in pancreatic beta cells was used to delineate the pancreas and was coregistered with PET and X-ray computed tomography images. This strategy enabled unambiguous identification of the pancreas on PET images, permitting accurate quantification of the pancreatic PET signal. We show here that, after conditional, specific, and rapid mouse beta-cell ablation, beta-cell loss was detected by bioluminescence imaging but not by PET imaging, given that the pancreatic signal provided by three PET radiotracers was not altered. To determine whether these ligands bound human beta cells in vivo, we imaged mice transplanted with luciferase-expressing human islets. The human islets were imaged by bioluminescence but not with the PET ligands, indicating that these vesicular monoamine transporter 2-directed ligands did not specifically bind beta cells. These data demonstrate the utility of coregistered multimodal imaging as a platform for evaluation and validation of candidate ligands for imaging islets.
To determine if glucose management in postcardiothoracic surgery patients with a combined intravenous (IV) and subcutaneous (SC) insulin regimen reduces mortality and morbidity in patients with diabetes and stress-induced hyperglycemia.Retrospective review of 614 consecutive patients who underwent cardiothoracic (CT) surgery in 2005 was performed to evaluate the incidence and treatment of postoperative hyperglycemia and operative morbidity and mortality. Hyperglycemic patients (glucose >6.05 mmol/l) were treated with IV insulin in the intensive care unit (ICU) followed by SC insulin (outside ICU). Subgroup analysis was performed on 159 coronary artery bypass grafting (CABG)-only patients.Among all CT surgeries, patients with a preoperative diagnosis of diabetes had higher rates of postoperative mortality (7.3 vs. 3.3%; P = 0.03) and pulmonary complications (19.5 vs. 11.6%; P = 0.02) but had similar rates of infections and cardiac, renal, and neurological complications on univariate analysis. However, on multivariate analysis, a preoperative diagnosis of diabetes was not a significant factor in postoperative mortality or pulmonary complications. In CABG-only patients, no significant differences were seen in outcomes between diabetic and nondiabetic patients. Independent of diabetic status, glucose > or =11 mmol/l on ICU admission was predictive of higher rates of mortality and renal, pulmonary, and cardiac postoperative complications.A combination of IV insulin (in the ICU) and SC insulin (outside the ICU), a less costly and less nursing-intensive therapy than 3 days of IV insulin postoperatively, results in a reduction of the increased surgical morbidity and mortality in diabetic patients after CT surgery.
During the last few years a number of articles have appeared on the dilated duodenum of the adult, and this condition is now recognized as a definite clinical entity. The symptoms, signs and x-ray appearance give a rather definite picture. In the adult, the condition is usually the result of some embryonic band, malformation, adhesions or compression by mesenteric root and artery. Although the subject of dilated duodenum has not been touched on by the pediatrician, there is no physical reason why the same picture might not occur in the infant and child. The case which will be reported here is one of constriction of the duodenum due to malformation and compression by the root of the mesentery. The history is typical of that of a dilated duodenum in the adult, and reemphasizes a more careful study of persistent vomiting in infancy and childhood and further dependence on the x-ray
Abstract Disclosure: J.A. Henske: None. G. Beach: None. A. Albashaireh: None. Background: Managing hyperglycemia and hypoglycemia before, during, and after aerobic exercise remains one of the greatest challenges for those living with type 1 diabetes. Several publications offer guidelines and recommendations but it is not well established to what extent these are followed by those living with diabetes. In order to assess the implementation and awareness of these guidelines and in particular guidelines around risk of hypoglycemia and safety recommendations, we created an online survey which was posted to focused social media groups limited to adults with type 1 diabetes who run, jog, or walk for exercise. Results: The entire 96-question survey was completed by 102 adults with a mean age of 42 and a mean duration of diabetes of 20 years. The self-reported average HbA1c of respondents was 7.1%. 68% of respondents reported exercise 4 or more days per week. Average mileage was 23 miles per week. The respondents were predominantly female (69%), Caucasian (94%), and from the United States (78%). There was a high rate of technology use as 97% of respondents report using CGM and 75% are using insulin pumps. 80% reported learning about diabetes and exercise mostly from trial and error, 46% from social media, 32% from their medical team, 28% from online searches, some using multiple methods. 27% of respondents reported fear of hypoglycemia as a significant barrier to exercise and 36% reported increased glucose variability as a result of exercise. 19% of respondents reported having hypoglycemia unawareness. 3% reported never having symptoms of hypoglycemia at any glucose level, 21% feel first symptoms with BG <50mg/dL, 26% at 50-60 mg/dL, and 40% at 60-70mg/dL. Despite published guidelines, 73% reported that they exercise even if severe hypoglycemia <50mg/dL in the last 24 hours, 74% do not check for ketones even if unexplained hyperglycemia >250mg/dL prior to exercise. 11% reported exercising with ketones present in blood or urine. 10% reported developing DKA after exercise. 86% experienced the need to stop exercise due to hypoglycemia and 18% reported a severe hypoglycemic event during exercise. 49% report not wearing diabetes identification during exercise. 41% reported difficulty with overnight hypoglycemia after exercise. Conclusion: In a real-world survey of 102 individuals with relatively well-controlled type 1 diabetes (mean A1c 7.1%) who walk, run, or jog extensively for exercise (23 miles per week), hypoglycemia awareness and management is a significant concern and barrier for them. Implementation science efforts and increased awareness of current guidelines and development of an educational curriculum surrounding type 1 diabetes and exercise may prove helpful to improve outcomes. Presentation: Thursday, June 15, 2023
