Context Immune checkpoint inhibitors (ICIs) have gained a revolutionary role in management of many advanced malignancies. However, immune-related endocrine events (irEEs), have been associated with their use. irEEs have non-specific clinical presentations and variable timelines, making their early diagnosis challenging. Objective To identify risk factors, timelines, and prognosis associated with irEEs development. Design and setting Retrospective observational study within the Cleveland Clinic center. Patients Metastatic cancer adult patients who received ICIs were included. Methods 570 charts were reviewed to obtain information on demographics, ICIs used, endocrine toxicities, cancer response to treatment with ICI, and overall survival. Main Outcome Measures Incidence of irEEs, time to irEEs development, and overall survival of patients who develop irEEs. Results The final cohort included 551 patients. The median time for the diagnosis of irEEs was 11 weeks. Melanoma was associated with the highest risk for irEEs (31.3%). Ipilimumab appeared to have the highest percentage of irEEs (29.4%), including the highest risk of pituitary insufficiency (11.7%), the most severe (Grade 4 in 60%) and irreversible (100%) forms of irEEs. 45 % of patients with irEEs had adequate cancer response to ICI compared to 28.3 % of patients without irEEs (p= 0.002). Patients with irEEs had significantly better survival compared to patients without irEEs (P <0.001). Conclusions In the adult population with metastatic cancer receiving treatment with ICI, irEEs development may predict tumor response to immunotherapy and a favorable prognosis. Ipilimumab use, combination ICI therapy, and melanoma are associated with a higher incidence of irEEs.
IntroductionInsulin pumps are increasingly being used as a method of insulin delivery in patients with type 1 diabetes mellitus (T1DM). Diabetic ketoacidosis (DKA) is a serious complication of T1DM. This study aims to identify the causes of DKA in patients with T1DM on continuous subcutaneous insulin infusion (CSII) and to compare these with patients with T1DM on multiple daily insulin injections (MDIIs).Research design and methodsThis is a prospective observational study between January and June 2019 at the Cleveland Clinic Fairview Hospital. Demographic, clinical, and biochemical data were obtained from chart review. A questionnaire to explore additional clinical data relating to DKA was administered, with additional items for patients on the insulin pump.ResultsSeventy-four patients were admitted with a diagnosis of DKA between the period of January and June 2019. Of these, 45 met the inclusion criteria and 43 consented. These were divided into two groups: group 1 included patients on MDII and group 2 included CSII. Overall, the most common precipitating factor for developing DKA was insulin non-adherence, seen in 51.2% of the cases. The most common cause of DKA in group 2 was pump/tubing related to 55% of the cases.ConclusionDespite non-adherence being common in both CSII and MDII, a combination of social factors, education and insulin pump malfunction, such as pump/tubing problems, might be playing a pivotal role in DKA etiology in young adults with T1DM, especially in CSII users. Continued education on pump use may reduce the rate of DKA in pump users.
Background: Cabergoline and Bromocriptine are ergot derivative long-acting dopamine agonist that are very effective and well tolerated in patients with hyperprolactinemia. A rare and unwanted side effect of Bromocriptine is priapism, which has hardly ever been report in literature and it’s not cited under the medication insert. The underlying mechanism is not totally clear, but it is well known that dopaminergic pathways in the central nervous system are of importance for male sexual behavior and penile erection. Lesser is known about Cabergoline and priapism with only one case report in the literature (1). Clinical Case: A 65 yr old African American male with a past medical history significant for obesity, essential hypertension, and recent history of frontal headaches was found to have a pituitary macroadenoma. Brain MRI demonstrated 11 x 12 x 9 mm enhancing lesion within the right lateral sella turcica. The lesion extended laterally to abut the right cavernous ICA without vascular encasement or extension into the right temporal skull base. Prolactin level was 276.3 ng/mL (2.1-15.0 ng/mL). He was started on Cabergoline 0.5 mg weekly. 60 days after starting Cabergoline he presented to the ED with a painful penile erection lasting >12 hours. He did not take any Phosphodiesterase (PDE) inhibitors and had no other recent change in medications. He denied any history of sickle cell disease. His most recent dose of Carbergoline was the day prior to the ED visit. He was seen by a Urologist in the ED and confirmed to have a low flow Priapism and underwent aspiration of intracorporal bodies. He was discharged home on pseudoephedrine and pain medications. Carbergoline was discontinued. He has had no further episodes of Priapism since discontinuation of Cabergoline. Conclusion: The time between drug use and occurrence, absence of other offending medications or precipitating factors and no further priapism episodes once treatment was discontinued suggests a priapism as a rarely reported side effect of Cabergoline. (1) References: 1.E.de la Pena Zarzuelo, V. Hernandez Canas and C. Llorente Abarca, Department of Urology, Hospital Universitario Fundacion Alcorcon, Madrid, Spain
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