Objective To assess the response of serum triglycerides (TG) to continuous insulin infusion (CII) in adults with hypertriglyceridemia-associated acute pancreatitis (HTGP). Methods Retrospective analysis of TG response to standardized CII therapy in 77 adults admitted to intensive care with TG >1000 mg/dL and HTGP. Results Participants had initial TG 3869.0 [2713.5, 5443.5] mg/dL and were 39.3 ± 9.7 years old, 66.2% males, 58.4% Hispanic, BMI 30.2 [27.0, 34.8] kg/m2, 74.0% with diabetes mellitus (DM) and 50.6% with excess alcohol use. TG-goal, defined as ≤1,000 ± 100 mg/dL, was achieved in 95%. Among the 73 TG-goal achievers (responders), 53.4% reached TG-goal in <36 hours after CII initiation (rapid responders). When compared to slow responders taking≥36 hours, rapid responders had lower initial TG (2862.0 [1965.0, 4519.0] vs 4814.5 [3368.8, 6900.0] mg/dL), BMI (29.4 [25.9, 32.8] vs 31.9 [28.2, 38.3] kg/m2), DM prevalence (56.4 vs 94.1%), and reached TG-50% (half of respective initial TG) faster (12.0 [6.0, 17.0] vs 18.5 [13.0, 32.8] hours). Those with DM (n = 57) vs non-DM (n = 20) were obese (31.4 [28.0, 35.6] vs 27.8 [23.6, 30.3] kg/m2), took longer to reach TG-final (41.0 [25.0, 60.5] vs 14.5 [12.5, 25.5] hours) and used more daily insulin (1.7 [1.3, 2.1] vs 1.1 [0.5, 1.9] U/kg/day). Among those with DM, the rapid responders had higher daily use of insulin vs slow responders 1.9 [1.4, 2.3] vs 1.6 [1.1, 1.8] U/kg/day. All results significant. In multivariable analysis, predictors of faster TG response were absence of DM, lower BMI and initial TG. Conclusion CII was effective in reaching TG-goal in 95% of patients with HTGP. Half achieved TG-goal within 36 hours. Presence of DM, higher BMI and initial TG slowed the time to reach TG-goal. These baseline parameters and rate of decline to TG-50% may be real-time indicators to initiate and adjust the CII for quicker response.
Background: Obesity has long been considered a risk factor for individual morbidity and mortality for numerous cardiopulmonary diseases. However, multiple studies have shown that patients who are overweight or obese according to BMI have better inpatient outcomes. Objective: To demonstrate the effect of obesity on outcomes of patients admitted for diabetes with and without complications. Method: Data were extracted from the Nationwide Inpatient Sample (NIS) Database for 2016 and 2017. The numbers in the database are weighted to optimize national estimates. Hospitalizations involving all adults with a principal diagnosis of type 1 and type 2 DM were included. This group was further categorized based on the presence of obesity, defined as BMI >30, as a secondary diagnosis. The primary outcome was inpatient mortality and secondary outcomes were Length of stay (LOS) and Total hospital Charge (THC). Multivariate regression analysis was used to adjust for possible confounders. Results: Around 1,031,009 hospitalizations had a principal diagnosis of DM types 1 and 2. This group had a prevalence of 15.67% of obesity as a secondary diagnosis. Inpatient mortality occurred in 6285 cases (0.61%). After accounting for age, sex, disease severity and type of diabetes, the adjusted odds ratio (aOR) for mortality in obese patients was 0.63 (95% CI: 0.526 - 0 .762, p< 0.001) compared to non-obese patients. Obese patients however, had adjusted increase in THC of $560 (95% CI: -347 - 1467, p=0.226) and adjusted increase in LOS of 0.3 days (95% CI: 0.3 - 0.4, p<0.001). Conclusions: In patients hospitalized with a principal diagnosis of diabetes and its complications, obese patients had a statistically lower mortality rate. Hence, there seems to be growing evidence for the obesity paradox. More research needs to be done to determine the factors responsible for this recurrent phenomenon. Disclosure H. Shaka: None. M. Padilla Sorto: None. T.A. Gomez: None. E. Edigin: None. J. Xu: None. S.T. Yap: None.
Background: Diabetic ketoacidosis (DKA) is managed with insulin and fluids, which can be challenging in patients with CKD. Diabetes is a common cause of CKD. Objective: To ascertain if patients admitted with DKA with CKD had worse outcomes compared to patients without CKD. Method: Data were extracted from the Nationwide Inpatient Sample (NIS) Database for 2016 and 2017. The numbers in the database are weighted to optimize national estimates. Hospitalizations involving adults with a principal diagnosis of DKA were included. This group was further categorized based on the presence of CKD as a secondary diagnosis. The primary outcome was inpatient mortality and secondary outcomes were Length of stay (LOS) and Total hospital Charge (THC). Multivariate regression analysis was used to adjust for possible confounders. Results: There were 245,170 adults who had a principal discharge diagnosis of DKA, of which 22700 had a secondary diagnosis of stage 1-5 CKD or ESRD. Those with CKD were significantly older on average (45.1 vs. 34.7 years) but without sex variation, compared to those without CKD. A total of 650 inpatient mortality (0.27%) occurred in patients with DKA, 135 occurring in patients with CKD (0.60%). After accounting for age, sex, disease severity and type of diabetes, the adjusted odds ratio (aOR) for mortality in patients with CKD compared to those without CKD was 0.89 (95% CI: 0.511 1.551, p= 0.682). CKD patients had an adjusted increase in total hospital charge of $5970 (95% CI: 2823 - 9116, p<0.001) and adjusted increase in length of hospitalization of 0.6 days ((95% CI: 0.3 - 0.8, p<0.001). Conclusions: In patients hospitalized with a principal diagnosis of DKA, there was no significant difference in mortality among patients with co-existing CKD. A modest increase in LOS and THC was however noted in those with CKD which was statistically significant. More research needs to be done to elucidate the effect of CKD stages on these outcomes. Disclosure H. Shaka: None. E. Edigin: None. T.A. Gomez: None. J. Xu: None. S.T. Yap: None. M. Padilla Sorto: None.
Background: Diabetes mellitus (DM) is a multisystemic disorder, known to be associated with worse outcomes of multiple conditions. Objectives: This study aims to determine if diabetes has an impact on outcomes of hospitalizations primarily for SLE. Methods: Data were extracted from the Nationwide Inpatient Sample (NIS) 2016 and 2017 database. The NIS was searched for SLE as the principal diagnosis for hospitalizations in 2016 and 2017, with and without DM as a secondary diagnosis, using ICD-10 codes. Adult Patients from the above groups were included. The primary outcome was inpatient mortality, while secondary outcomes were length of stay (LOS) and Total hospital charge. Multivariate logistic and linear regression analysis were used to adjust for possible confounders for the primary and secondary outcomes respectively. Results: 20630 hospitalizations were for adult patients, who had principal diagnosis of SLE. 18560 (90.0%) of these hospitalizations had no secondary diagnosis of DM and 2070 (10.0%) had a secondary diagnosis of DM. A total of 255 inpatient mortality (1.23%) occurred in SLE hospitalizations, 35 (1.19%) of which occurred in patients with DM. The adjusted odds ratio (AOR) of inpatient mortality for SLE with DM compared to without DM was 0.554 (95% CI: 0.233 - 1.315, P=0.180). Hospitalizations with SLE and DM had a decreased adjusted mean LOS of 2.1 days (95% CI -3.0 - {-1.1}, P=0.000) compared to without DM. The adjusted mean total hospital charge for SLE and DM hospitalizations was also decreased by $24875 compared to without DM (95% CI -36154 - {-13596}, P=0.000). Conclusions: There was no statistically significant difference in inpatient mortality of hospitalizations for SLE with DM compared to SLE without DM. Interestingly, SLE with DM hospitalizations has a shorter LOS and lower total hospital charge compared to without DM. Disclosure E. Edigin: None. H. Shaka: None. J. Xu: None. S.T. Yap: None. M. Padilla Sorto: None.
Introduction: Cancer Immunotherapy (CI) is rapidly advancing field with different immune check point inhibitors (ICPi) targeting different cancers, with Durvalumab being one of the recent ICPi. Durvalumab induced endocrinopathies are common, mostly irreversible and if managed appropriately do not require cessation. Here we are presenting a patient (pt) who developed 3 different endocrinopathies simultaneously. Case: A 69 year old female with type 2 diabetes mellitus (T2DM), Stage III lung cancer was started on Durvalumab for unresectable cancer. 2 months later, presented to Emergency Department with fatigue, poor appetite, dizziness, palpitations, heat intolerance, polydipsia, polyuria. Labs suggestive of Thyrotoxicosis, blood glucose of 600mg/dl, AM Cortisol & ACTH consistent with central adrenal insufficiency (AI). Her previously well controlled T2DM (A1C 6.1%), suddenly became uncontrolled (A1C 9.5%), Antibodies were positive suggesting superimposition of autoimmune diabetes (AID). Pt was discharged on Methimazole (MMI), hydrocortisone (HC) and modified Insulin regimen. After discharge patient stopped MMI and HC. TFT’s 2 weeks after stopping MMI were suggestive of hypothyroidism. AM Cortisol 10 days after stopping HC was normal, her subsequent AM cortisol remained normal. Her clinical picture with rapid conversion of thyrotoxicosis to hypothyroidism is suggestive of Thyroiditis from Durvalumab. Discussion: Durvalumab an ICPi is a programmed death-ligand 1(PD-L1) blocking antibody, initially approved for urothelial cancer, but was later shown to be effective in other solid tumors. Immune-related adverse events (irAE) due to Durvalumab therapy are mostly thyroid-related, AID and AI rarely reported. Pathogenesis of AID is likely related to PD-L1 blockage on autoreactive T cells that target islet cells. Ansari et al showed the development of autoimmune antibodies in a mouse model, later demonstrated in few human studies. irAE can affect more than one endocrine gland, typically occur in 10-11 weeks, can happen at same time or in succession. ICPi-induced hypophysitis should be considered prior to committing to diagnosis of primary AI. American Society of Clinical Oncology (ASCO) recommends screening for endocrine irAE with TSH/FT4 every 4-6 weeks, checking BG at baseline, every cycle for 12 weeks and then every 3 to 6 weeks. In patients with suspected type 1 DM, ASCO recommends checking antibodies, insulin, and, C-peptide levels. For AI, routine diagnostic work-up not recommended if asymptomatic. Conclusion: Our pt with T2DM developed AID, thyroiditis which progressed to hypothyroidism, central AI. This is a rare case where pt developed all 3 endocrinopathies secondary to durvalumab and also a rare case where AI self-resolved when pt still on durvalumab.
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