Enhancing outcome prediction by applying the 2019 WHO DM classification to adults with hyperglycemic crises: A single-center cohort in Thailand.

BACKGROUND AND AIMS: Hyperglycemic crisis is a metabolic catastrophe which can occur in any type of diabetes. In 2019, the World Health Organization (WHO) revised the classification of diabetes mellitus (DM) and established two new hybrid forms, latent autoimmune diabetes in adults (LADA) and ketosis-prone type 2 diabetes (T2D). This study aimed to determine clinical outcomes after a hyperglycemic crisis event in people with diabetes classified subtypes by 2019 WHO DM classification. METHODS: A five-year (2015-2019) retrospective study of adult patients admitted with hyperglycemic crises was conducted. Types of diabetes were recategorized based on the 2019 WHO DM classification. Clinical characteristics, in-admission treatment and complications, long-term follow-up outcomes, and mortality were collected, analyzed, and compared. RESULTS: A total of 185 admissions occurred in 136 patients. The mean age was 50.6 ± 18.4 years (49.3 % men). The annual average incidence of hyperglycemic crises was 5.2 events/1000 persons. The proportion of type 1 diabetes, T2D, LADA, ketosis-prone T2D, and pancreatic DM were 15.4 %, 69.1 %, 2.2 %, 11 %, and 2.2 %, respectively. In-hospital mortality was 3.7 % while cumulative mortality totaled 19.1 %. During the 24-month follow-up, ketosis-prone T2D had the highest success of insulin discontinuation (HR 6.59; 95 % CI 6.69-319.4; p < 0.001), while T2D demonstrated the highest mortality compared to others (HR, 2.89; 95%CI 1.15-6.27; p = 0.02). CONCLUSION: The reclassification of diabetes based on 2019 WHO DM classification helped elucidate differences in long-term outcomes and mortality among DM types. The new classification, which separates ketosis-prone T2D from standard T2D, should be encouraged in clinical practice for precise and individualized management.

Outcomes of a multidisciplinary transition clinic for youth with type 1 diabetes.

BACKGROUND: Emerging adults with type 1 diabetes (T1D) have several challenges regarding diabetes management and care transition from pediatric to adult services. In this study we aimed to assess the effectiveness of the newly established transition clinic for emerging adults with T1D. METHODS: We conducted an observational study of emerging adults with T1D treated in a transition clinic jointly operated by a pediatric and adult multidisciplinary care team during 2019-2021. A retrospective chart review of hemoglobin A1c (HbA1c), frequency of clinic attendance, acute diabetes-related complications, assessment of gaps in knowledge and behavior, and psychosocial outcomes was analyzed. RESULTS: A total of 21 patients with T1D were included. Median age at the transfer to the transition clinic was 24 years (range 21-34). Fifteen patients (71%) were successfully transferred to adult services; mean duration of follow-up at the transition clinic was 9.2 months (SD 3.9). None of the patients was lost to follow-up or experienced serious diabetes related complications. Mean (95% confidence interval) HbA1c levels decreased from 8.97% (7.87-10.07) at baseline to 8.25% (7.45-9.05) at the most recent visit (p = 0.01). A proportion of patients achieving the glycemic target (HbA1c < 7.5%) was increased from 24% at the first visit to 38% at the most recent visits. Patients' HbA1c levels at the adult clinic continued a favorable trend. Seven patients (33%) were identified as having symptoms of depression. Knowledge and behavioral gaps were identified and counselled by clinical care team. CONCLUSION: The multidisciplinary transition clinic has shown to be beneficial in terms of improving glycemic control, maintaining continuity of care and clinic attendance.

The Accuracy of Continuous Glucose Monitoring in the Medical Intensive Care Unit.

OBJECTIVE: To assess the accuracy of continuous glucose monitoring (CGM) in medical intensive care unit (MICU) patients. METHODS: A Medtronic Enlite® sensor accuracy was assessed versus capillary blood glucose (CBG) and plasma glucose (PG) using the mean absolute relative difference (MARD), surveillance error grid (SEG) analysis and modified Bland-Altman plots. RESULTS: Using CBG as a reference, MARD was 6.6%. Overall, 99.7% of the CGM readings were within the "no risk" zone. No significant differences in accuracy were seen within vasopressor subgroups. Using PG as the reference, MARD was 8.8%. The surveillance error grid analysis showed 95.2% of glucose readings were within the "no risk" zone. There were no device-related adverse events. CONCLUSION: The CGM sensor showed acceptable accuracy in MICU patients, regardless of vasopressor use.

Anticipation of Historical Exercise Patterns by a Novel Artificial Pancreas System Reduces Hypoglycemia During and After Moderate-Intensity Physical Activity in People with Type 1 Diabetes.

Objective: Physical activity is a major challenge to glycemic control for people with type 1 diabetes. Moderate-intensity exercise often leads to steep decreases in blood glucose and hypoglycemia that closed-loop control systems have so far failed to protect against, despite improving glycemic control overall. Research Design and Methods: Fifteen adults with type 1 diabetes (42 ± 13.5 years old; hemoglobin A1c 6.6% ± 1.0%; 10F/5M) participated in a randomized crossover clinical trial comparing two hybrid closed-loop (HCL) systems, a state-of-the-art hybrid model predictive controller and a modified system designed to anticipate and detect unannounced exercise (APEX), during two 32-h supervised admissions with 45 min of planned moderate activity, following 4 weeks of data collection. Primary outcome was the number of hypoglycemic episodes during exercise. Continuous glucose monitor (CGM)-based metrics and hypoglycemia are also reported across the entire admissions. Results: The APEX system reduced hypoglycemic episodes overall (9 vs. 33; P = 0.02), during exercise (5 vs. 13; P = 0.04), and in the 4 h following (2 vs. 11; P = 0.02). Overall CGM median percent time <70 mg/dL decreased as well (0.3% vs. 1.6%; P = 0.004). This protection was obtained with no significant increase in time >180 mg/dL (18.5% vs. 16.6%, P = 0.15). Overnight control was notable for both systems with no hypoglycemia, median percent in time 70-180 mg/dL at 100% and median percent time 70-140 mg/dL at ∼96% for both. Conclusions: A new closed-loop system capable of anticipating and detecting exercise was proven to be safe and feasible and outperformed a state-of-the-art HCL, reducing participants' exposure to hypoglycemia during and after moderate-intensity physical activity. ClinicalTrials.gov NCT03859401.

Newly Discovered Abnormal Glucose Tolerance in Patients With Acute Myocardial Infarction and Cardiovascular Outcomes: A Meta-analysis.

BACKGROUND: The prevalence of unrecognized abnormal glucose tolerance (AGT) and the incidence of recurrent cardiovascular (CV) events in patients with acute myocardial infarction (MI) has not been systematically evaluated. PURPOSE: The purposes of this study were to define the prevalence of newly discovered AGT and examine the risk of recurrent major adverse cardiac events (MACE) and mortality in patients with acute MI. DATA SOURCES: Medline, Embase, Cochrane Library, and Google Scholar were searched for relevant articles. STUDY SELECTION: Inclusion criteria included prospective studies in patients with acute MI without known history of diabetes; AGT diagnosed using fasting plasma glucose, 2-h oral glucose tolerance test, or HbA1c; and incidence of MACE and/or all-cause mortality in newly discovered AGT. DATA EXTRACTION: Two investigators extracted the data. Pooled prevalence, incidence rate ratios, and hazard ratios (HRs) were calculated using random-effects models. DATA SYNTHESIS: In 19 studies (n = 41,509, median follow-up 3.1 years), prevalence of newly discovered AGT was 48.4% (95% CI 40.2-56.6). Prediabetes had a higher mortality risk than normal glucose tolerance (NGT) (HR 1.36 [95% CI 1.13-1.63], P < 0.001) and MACE (1.42 [1.20-1.68], P < 0.001). Newly diagnosed diabetes had higher mortality risk than NGT (1.74 [1.48-2.05], P < 0.001) and MACE (1.54 [1.23-1.93], P < 0.001). LIMITATIONS: This is not a meta-analysis of individual patient data. Time-to-event analysis and covariate-adjusted analysis cannot be conducted to examine heterogeneity reliably. Few studies reported CV death and heart failure hospitalizations. CONCLUSIONS: Patients with acute MI have a high prevalence of newly discovered AGT. Aggressive risk reduction strategies in this population, especially in those with prediabetes, are warranted.

Clinical Characteristics and Treatment Outcomes in Endogenous Cushing's Syndrome: A 15-Year Experience from Thailand.

The most common subtype of endogenous Cushing's syndrome (CS) is Cushing's disease (CD), with higher proportions of adrenal CS reported from Asia, compared to other continents. However, little was known about CS in this territory. This study was to investigate the distribution, clinical characteristics, and treatment outcomes of CS in a single tertiary hospital in Thailand. We performed a retrospective evaluation of 82 patients with endogenous CS during 2001-2015. The most common subtype was CD, followed by adrenal CS and ectopic ACTH syndrome (EAS), respectively. Weight gain was the most common presentation. Normal body mass index (BMI), Asian cutoff, was observed in 33% of patients. Specific features of CS (plethora, muscle weakness, bruising, and/or wide purplish striae) were documented in less than half of patients. The median age, adrenocorticotropic hormone (ACTH), and urinary free cortisol (UFC) concentrations were significantly different among 3 subtypes of CS and were highest among patients with EAS. An initial remission rate after transsphenoidal surgeries in CD was 62%, with higher rates in pituitary microadenomas compared to macroadenomas. All patients with unilateral adrenal disease achieved CS remission after adrenal surgeries. Patients with EAS achieved CS remission mostly from bilateral adrenalectomy. The highest mortality rate was observed in the EAS group. These findings were consistent with previous studies in Asia, with more proportions ACTH-independent CS.

Evidence Against an Important Role of Plasma Insulin and Glucagon Concentrations in the Increase in EGP Caused by SGLT2 Inhibitors.

Sodium-glucose cotransport 2 inhibitors (SGLT2i) lower plasma glucose but stimulate endogenous glucose production (EGP). The current study examined the effect of dapagliflozin on EGP while clamping plasma glucose, insulin, and glucagon concentrations at their fasting level. Thirty-eight patients with type 2 diabetes received an 8-h measurement of EGP ([3-3H]-glucose) on three occasions. After a 3-h tracer equilibration, subjects received 1) dapagliflozin 10 mg (n = 26) or placebo (n = 12); 2) repeat EGP measurement with the plasma glucose concentration clamped at the fasting level; and 3) repeat EGP measurement with inhibition of insulin and glucagon secretion with somatostatin infusion and replacement of basal plasma insulin and glucagon concentrations. In study 1, the change in EGP (baseline to last hour of EGP measurement) in subjects receiving dapagliflozin was 22% greater (+0.66 ± 0.11 mg/kg/min, P < 0.05) than in subjects receiving placebo, and it was associated with a significant increase in plasma glucagon and a decrease in the plasma insulin concentration compared with placebo. Under glucose clamp conditions (study 2), the change in plasma insulin and glucagon concentrations was comparable in subjects receiving dapagliflozin and placebo, yet the difference in EGP between dapagliflozin and placebo persisted (+0.71 ± 0.13 mg/kg/min, P < 0.01). Under pancreatic clamp conditions (study 3), dapagliflozin produced an initial large decrease in EGP (8% below placebo), followed by a progressive increase in EGP that was 10.6% greater than placebo during the last hour. Collectively, these results indicate that 1) the changes in plasma insulin and glucagon concentration after SGLT2i administration are secondary to the decrease in plasma glucose concentration, and 2) the dapagliflozin-induced increase in EGP cannot be explained by the increase in plasma glucagon or decrease in plasma insulin or glucose concentrations.

Changes in Testosterone Levels and Sex Hormone-Binding Globulin Levels in Extremely Obese Men after Bariatric Surgery.

Objective. Obesity is a risk factor for hypogonadotropic hypogonadism in men. Weight loss has been shown to improve hypogonadism in obese men. This study evaluated the early changes in sex hormones profile after bariatric surgery. Methods. This is a prospective study including 29 morbidly obese men. Main outcomes were changes in serum levels of total testosterone (TT), free testosterone (cFT), SHBG, estradiol, adiponectin, and leptin at 1 and 6 months after surgery. Results. The mean age of patients was 31 ± 8 years and the mean BMI was 56.8 ± 11.7 kg/m2. Fifteen patients underwent Roux-en-Y gastric bypass and 14 patients underwent sleeve gastrectomy. At baseline, 22 patients (75.9%) had either low TT levels (<10.4 nmol/L) or low cFT levels (<225 pmol/L). Total testosterone and SHBG levels increased significantly at 1 month after surgery (p ≤ 0.001). At 6 months after surgery, TT and cFT increased significantly (p ≤ 0.001) and 22 patients (75.9%) had normalized TT and cFT levels. There were no changes in estradiol levels at either 1 month or 6 months after surgery. Conclusions. Increases in TT and SHBG levels occurred early at 1 month after bariatric surgery while improvements in cFT levels were observed at 6 months after bariatric surgery.

Acalculous Cholecystitis as the Initial Presentation of Systemic Diffuse Large B-Cell Lymphoma.

The involvement of the gallbladder in systemic lymphoma is extremely rare. We report a challenging case of systemic diffuse large B-cell lymphoma (DLBCL) that initially presented with septic shock from acalculous cholecystitis. After extensive investigation, DLBCL was found to be the underlying cause of gallbladder disease.