Aims Diabetic ketoacidosis (DKA) is an emergency with high morbidity and mortality. This study examined patient factors associated with hospitalization for recurrent DKA. Methods Characteristics of 265 subjects admitted for DKA at Hennepin County Medical Center between January 2017 and January 2019 were retrospectively analyzed. Differences between subjects with a single admission versus multiple were reviewed. Results Forty-eight out of 265 patients had recurrent DKA. Risk factors included African American race (adjusted odds ratio (aOR) versus white non-Hispanic = 4.6, 95% CI 1.8–13, p = 0.001) or other race/ethnicity (aOR = 8.6, 2.9–28, p < 0.0001), younger age (aOR 37-52y versus 18-36y = 0.48, 0.19–1.16, p = 0.10; aOR 53-99y versus 18-36y = 0.37, 0.12–0.99, p = 0.05), type 1 diabetes mellitus (aOR = 2.4, 1.1–5.5, p = 0.04), ever homeless (aOR = 2.5, 1.1–5.4, p = 0.03), and drug abuse (aOR = 3.2, 1.3–7.8, p = 0.009). DKA cost a median of $29,981 per admission. Conclusions Recurrent DKA is costly, and social determinants are strong predictors of recurrence. This study highlights the need for targeted preventative care programs.

Objective: Pancreatic neuroendocrine tumors secreting proinsulin and insulin could lead to life-threatening hypoglycemia. We aim to show this can be avoided by utilizing continuous glucose monitoring.Methods: We describe a case of a 55-year-old female with hypoglycemia unawareness and seizures diagnosed with proinsulinoma. She utilized an intermittently scanned continuous glucose monitor (isCGM) to monitor hypoglycemia preoperatively.Results: The patient underwent biochemical and radiographic evaluation to confirm the diagnosis of proinsulinoma. Utilizing isCGM to monitor blood glucose, she was able to prevent hypoglycemia-related seizures prior to definitive surgery.Conclusion: In the time leading up to a definitive surgery, patients with proinsulinomas are at risk of hypoglycemic events leading to falls, seizures, and even death. isCGMs can be utilized for preoperative monitoring and treatment of hypoglycemia in these patients. (AACE Clinical Case Rep. 2019;5:e255-e258) Abbreviations: CGM = continuous glucose monitor; isCGM = intermittently scanned continuous glucose monitor; PNET = pancreatic neuroendocrine tumor e256 PNET with Seizures, AACE Clinical Case Rep. 2019;5(No. 4)

We describe an unusual case of a 55-year old female with a proinsulin secreting pancreatic endocrine adenoma. She presented with partial seizures, fasting hypoglycemia, and hypoglycemia unawareness. CT and MRI confirmed a hyper-enhancing lesion in the pancreatic body. She was effectively treated with prednisone and utilized a continuous glucose monitor (CGM) to identify and treat hypoglycemia while she awaited surgery. She underwent resection and the surgical specimen was neuroendocrine adenomatous tissue. This case has several important teaching points: [1] Fasting hypoglycemia requires a complete work up since proinsulinomas, although rare, can occur. [2] Whipple’s triad is not 100% sensitive in the work-up of hypoglycemia. Patients with persistent hypoglycemia may develop hypoglycemia unawareness. [3] Continuous glucose monitors (CGM) may provide an alternative or adjunct to standard medical therapy while patients await definitive surgery. Prednisone may also be an inexpensive and effective therapy. References1. Fadini GP MAVAea. Hypoglycemic Syndrome in a Patient with Proinsulin-Only Secreting Pancreatic Adenoma (Proinsulinoma). Case Reports in Medicine. 2011.2. Clark G, Sadur C, Puligandla B. Multiple proinsulin-secreting tumors of the pancreas treated by laparoscopic distal pancreatectomy and splenectomy. World Journal of Surgery. 2009;33(3):397-3993. F. J. Gomez-Perez DCRPAVCAASRMaJAR. Beta-cell adenomas without hyperinsulinemia with use of highly specific insulin radioimmunoassays: case report and review of literature. Endocrine Practice. 2010;16(4):660-663.4. Gury H, Rio F, Neamtu D, Boivin S. Insulinoma with hyperproinsulinemia: A two cases report. Annales d'Endocrinologie. 2002;63(3):240-242.5. Piovesan A, Pia A, Visconti G, al e. Proinsulin-secreting neuroendocrine tumor of the pancreas. Journal of Endocrinological Investigation. 2003;26(8):758-761.

The FreeStyle Libre flash glucose monitor (FGM) has made the use of continuous glucose monitors more accessible to the typical diabetes patient in an outpatient setting given the significantly lower cost and ease of use of FGM as compared to other systems. However, FGM is not labeled for use in a critically ill population. The critical care department at our institution queried the endocrine department about studying the use of FGM in critically ill patients. The interest of the critical care department was due to the potential of decrease in patient discomfort and decrease in time and effort of nursing and support staff related to the performance of fingerstick capillary glucoses if FGM was an adequate replacement measure. As of yet, there has been only minimal study of flash glucose monitoring in critically ill patients. One Australian study evaluated 8 patients in an ICU setting and determined that as compared with arterial blood glucose monitoring, flash glucose monitoring provided acceptable numerical and clinical accuracy.1 A Swedish study evaluated a total of 26 patients undergoing cardiac surgery and compared the use of FGM to use of a microdialysis intravascular system and concluded that the microdialysis system was more accurate, though in this study, only 25% of patients had diabetes. 2 To further investigate use of FGM in a critically ill population, we plan to undertake a single center, prospective, single arm study enrolling at least 20 and up to 40 patients. Inclusion criteria include a known diagnosis of type 1 or type 2 diabetes, age of 18 or older, and admission to the medical intensive care unit (MICU) with expected MICU stay of at least 48 hours. Participating subjects will have a sensor applied by a study investigator. After confirmation that the sensor is operational, the investigator will place opaque tape over the monitor to blind the monitor data. Nurses or medical assistants will conduct the standard of care fingerstick glucose monitoring per hospital protocol but will also have been notified of request to also pass FGM reader over the sensor at time of fingerstick glucose data collection. The primary objectives are to determine numerical accuracy in a critical care setting using the mean absolute relative difference and to determine clinical accuracy in a critical care setting using the surveillance error grid and the clarke error grid analyses. Preliminary data should be available by March, 2020. 1. Ancona P, Eastwood GM, Lucchetta L, Ekinci EI, Bellomo R, Martensson J. The performance of flash glucose monitoring in critically ill patients with diabetes. Crit Care Resusc 2017; 19: 167-174, June 2017. 2. Schierenbeck F, Franco-Cereceda A, Liska J. Accuracy of 2 Different Continuous Glucose Monitoring Systems in Patients Undergoing Cardiac Surgery: Intravascular Microdialysis Versus Subcutaneous Tissue Monitoring. Journal of Diabetes Science and Technology 2017, Vol. 11(1) 108–116

This prospective, open-label, randomized clinical trial compared the safety and efficacy of a basal bolus regimen using glargine U300 or glargine U100 for the management of general medicine and surgery patients with T2D. A total of 171 patients (age: 57±12 years, admission BG: 229±82 mg/dl and HbA1c: 9.5±2.2% [mean±SD]), treated with oral agents or insulin prior to admission, were randomized to glargine U300 (n=90) or glargine U100 (n=81). Total daily dose (TDD) started at 0.4 U/kg/d for BG: 140-200 mg/dl or 0.5 U/kg/d for BG: 201-400 mg/dl. Half of TDD was given as glargine U300 or U100 once daily and half as glulisine before meals. We adjusted insulin daily to a target BG: 70-180 mg/dl. We measured BG by capillary point of care (POC) testing before meals and bedtime. To further examine glucose differences, we placed a professional Freestyle Libre CGM in a subgroup of patients (n=82). Major outcomes included differences in mean daily BG and frequency of hypoglycemia between groups. There were no differences between glargine U300 and U100 in mean daily BG (POC: 188 ±41vs. 184±45 mg/dl, p=0.47; CGM: 172±45 vs. 165±47 mg/dl, p=0.42), percentage (%) of glucose readings between 70-180 mg/dl (POC: 50±25% vs. 52±27%, p=0.74; CGM: 55±26% vs. 56±27%, p=0.80), length of stay (median (IQR): 6.0 (4.0-8.0) vs. 4.0 (3.0, 7.0) days, p=0.07), hospital complications (6.7% vs. 11%, p=0.42), or insulin TDD (0.44±0.21 vs. 0.43±0.20 U/kg/day, p=0.74). There were no differences % of BG &lt;70 mg/dl (POC: 0.62±2.51 vs. 0.82±2.98, p&gt;0.99; CGM: 5.88±14.49 vs. 5.74±8.15, p= 0.35), but U300 resulted in significant lower rates of BG &lt;54 mg/dl (POC: 0% vs. 0.45±2.45, p=0.033, CGM: 0.82±1.39 vs. 2.18±4.16 p=0.23). In summary, our study indicates that hospital treatment with glargine U300 resulted in similar glycemic control and lower frequency of clinically significant hypoglycemia compared to glargine U100 in general medicine and surgery patients with T2D. Disclosure F.J. Pasquel: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. M. Lansang: None. A. Khowaja: None. R.J. Galindo: Advisory Panel; Self; Abbott, Novo Nordisk Inc., Sanofi US. Research Support; Self; Novo Nordisk Inc. M.A. Urrutia: None. S. Cardona: None. A. Shakally: None. R.C. Lyerla: None. I. Anzola: None. B.S. Albury: None. J. Haw: None. M. Fayfman: None. G. Davis: None. A. Migdal: None. P. Vellanki: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck & Co., Inc. Research Support; Self; National Institutes of Health. L. Peng: None. G.E. Umpierrez: Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc. Research Support; Self; AstraZeneca, Merck & Co., Inc., Novo Nordisk Inc., Sanofi US. Funding Sanofi US