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Frassetto LA, Masharani U. Effects of Alterations in Acid-Base Effects on Insulin Signaling. Int J Mol Sci 2024; 25:2739. [PMID: 38473990 DOI: 10.3390/ijms25052739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
Insulin tightly regulates glucose levels within a narrow range through its action on muscle, adipose tissue and the liver. The activation of insulin receptors activates multiple intracellular pathways with different functions. Another tightly regulated complex system in the body is acid-base balance. Metabolic acidosis, defined as a blood pH < 7.35 and serum bicarbonate < 22 mmol/L, has clear pathophysiologic consequences including an effect on insulin action. With the ongoing intake of typical acid-producing Western diets and the age-related decline in renal function, there is an increase in acid levels within the range considered to be normal. This modest increase in acidosis is referred to as "acid stress" and it may have some pathophysiological consequences. In this article, we discuss the effects of acid stress on insulin actions in different tissues.
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Affiliation(s)
- Lynda A Frassetto
- Department of Medicine, Division of Nephrology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Umesh Masharani
- Department of Medicine, Division of Endocrinology, University of California San Francisco, San Francisco, CA 94143, USA
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Leija RG, Curl CC, Arevalo JA, Osmond AD, Duong JJ, Huie MJ, Masharani U, Brooks GA. Enteric and systemic postprandial lactate shuttle phases and dietary carbohydrate carbon flow in humans. Nat Metab 2024:10.1038/s42255-024-00993-1. [PMID: 38388706 DOI: 10.1038/s42255-024-00993-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/24/2024] [Indexed: 02/24/2024]
Abstract
Dietary glucose in excess is stored in the liver in the form of glycogen. As opposed to direct conversion of glucose into glycogen, the hypothesis of the postprandial lactate shuttle (PLS) proposes that dietary glucose uptake is metabolized to lactate in the gut, thereby being transferred to the liver for glycogen storage. In the present study, we provide evidence of a PLS in young healthy men and women. Overnight fasted participants underwent an oral glucose tolerance test, and arterialized lactate concentration and rate of appearance were determined. The concentration of lactate in the blood rose before the concentration of glucose, thus providing evidence of an enteric PLS. Secondary increments in the concentration of lactate in the blood and its rate of appearance coincided with those of glucose, which indicates the presence of a larger, secondary, systemic PLS phase driven by hepatic glucose release. The present study challenges the notion that lactate production is the result of hypoxia in skeletal muscles, because our work indicates that glycolysis proceeds to lactate in fully aerobic tissues and dietary carbohydrate is processed via lactate shuttling. Our study proposes that, in humans, lactate is a major vehicle for carbohydrate carbon distribution and metabolism.
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Affiliation(s)
- Robert G Leija
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Casey C Curl
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Jose A Arevalo
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Adam D Osmond
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Justin J Duong
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Melvin J Huie
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, CA, USA
| | - George A Brooks
- Exercise Physiology Laboratory, Department of Integrative Biology, University of California, Berkeley, CA, USA.
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Rodriguez‐Valadez JM, Tahsin M, Masharani U, Park M, Hunink MGM, Yeboah J, Li L, Weber E, Berkalieva A, Avezaat L, Max W, Fleischmann KE, Ferket BS. Potential Mediators for Treatment Effects of Novel Diabetes Medications on Cardiovascular and Renal Outcomes: A Meta-Regression Analysis. J Am Heart Assoc 2024; 13:e032463. [PMID: 38362889 PMCID: PMC11010086 DOI: 10.1161/jaha.123.032463] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/30/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Prior research suggests clinical effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) are mediated by changes in glycated hemoglobin, body weight, systolic blood pressure, hematocrit, and urine albumin-creatinine ratio. We aimed to confirm these findings using a meta-analytic approach. METHODS AND RESULTS We updated a systematic review of 9 GLP-1RA and 13 SGLT2i trials and summarized longitudinal mediator data. We obtained hazard ratios (HRs) for cardiovascular, renal, and mortality outcomes. We performed linear mixed-effects modeling of LogHRs versus changes in potential mediators and investigated differences in meta-regression associations among drug classes using interaction terms. HRs generally became more protective with greater glycated hemoglobin reduction among GLP-1RA trials, with average HR improvements of 20% to 30%, reaching statistical significance for major adverse cardiovascular events (ΔHR, 23%; P=0.02). Among SGLT2i trials, associations with HRs were not significant and differed from GLP1-RA trials for major adverse cardiovascular events (Pinteraction=0.04). HRs for major adverse cardiovascular events, myocardial infarction, and stroke became less efficacious (ΔHR, -15% to -34%), with more weight loss for SGLT2i but not for GLP-1RA trials (ΔHR, 4%-7%; Pinteraction<0.05). Among 5 SGLT2i trials with available data, HRs for stroke became less efficacious with larger increases in hematocrit (ΔHR, 123%; P=0.09). No changes in HRs by systolic blood pressure (ΔHR, -11% to 9%) and urine albumin-creatinine ratio (ΔHR, -1% to 4%) were found for any outcome. CONCLUSIONS We confirmed increased efficacy findings for major adverse cardiovascular events with reduction in glycated hemoglobin for GLP1-RAs. Further research is needed on the potential loss of cardiovascular benefits with increased weight loss and hematocrit for SGLT2i.
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Affiliation(s)
- José M. Rodriguez‐Valadez
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Malak Tahsin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Umesh Masharani
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Meyeon Park
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of NephrologyUniversity of CaliforniaSan FranciscoCAUSA
| | - M. G. Myriam Hunink
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
- Department of RadiologyErasmus MCRotterdamthe Netherlands
- Center for Health Decision Sciences, Harvard TH Chan School of Public HealthBostonMAUSA
| | - Joseph Yeboah
- Section of Cardiovascular Medicine, Internal MedicineWake Forest University School of MedicineWinston SalemNCUSA
| | - Lihua Li
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Ellerie Weber
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Luuk Avezaat
- Department of EpidemiologyErasmus MCRotterdamthe Netherlands
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral SciencesUniversity of CaliforniaSan FranciscoCAUSA
| | - Kirsten E. Fleischmann
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
- Division of CardiologyUniversity of CaliforniaSan FranciscoCAUSA
| | - Bart S. Ferket
- Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount SinaiNew YorkNYUSA
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Klonoff DC, Wang J, Rodbard D, Kohn MA, Li C, Liepmann D, Kerr D, Ahn D, Peters AL, Umpierrez GE, Seley JJ, Xu NY, Nguyen KT, Simonson G, Agus MSD, Al-Sofiani ME, Armaiz-Pena G, Bailey TS, Basu A, Battelino T, Bekele SY, Benhamou PY, Bequette BW, Blevins T, Breton MD, Castle JR, Chase JG, Chen KY, Choudhary P, Clements MA, Close KL, Cook CB, Danne T, Doyle FJ, Drincic A, Dungan KM, Edelman SV, Ejskjaer N, Espinoza JC, Fleming GA, Forlenza GP, Freckmann G, Galindo RJ, Gomez AM, Gutow HA, Heinemann L, Hirsch IB, Hoang TD, Hovorka R, Jendle JH, Ji L, Joshi SR, Joubert M, Koliwad SK, Lal RA, Lansang MC, Lee WA(A, Leelarathna L, Leiter LA, Lind M, Litchman ML, Mader JK, Mahoney KM, Mankovsky B, Masharani U, Mathioudakis NN, Mayorov A, Messler J, Miller JD, Mohan V, Nichols JH, Nørgaard K, O’Neal DN, Pasquel FJ, Philis-Tsimikas A, Pieber T, Phillip M, Polonsky WH, Pop-Busui R, Rayman G, Rhee EJ, Russell SJ, Shah VN, Sherr JL, Sode K, Spanakis EK, Wake DJ, Waki K, Wallia A, Weinberg ME, Wolpert H, Wright EE, Zilbermint M, Kovatchev B. A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings. J Diabetes Sci Technol 2023; 17:1226-1242. [PMID: 35348391 PMCID: PMC10563532 DOI: 10.1177/19322968221085273] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. METHODS We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. RESULTS The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. CONCLUSION The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Jing Wang
- Florida State University College of Nursing, Tallahassee, FL, USA
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | - Michael A. Kohn
- University of California, San Francisco, San Francisco, CA, USA
| | - Chengdong Li
- Florida State University College of Nursing, Tallahassee, FL, USA
| | | | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, CA, USA
| | - David Ahn
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | | | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | | | | | - Ananda Basu
- University of Virginia, Charlottesville, VA, USA
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | | | | | | | | | | | - Kong Y. Chen
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | | | | | | | | | - Thomas Danne
- Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Juan C. Espinoza
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | - Thanh D. Hoang
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | - Linong Ji
- Peking University People’s Hospital, Peking University Diabetes Center, Beijing, China
| | | | | | | | | | - M. Cecilia Lansang
- Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Wei-An (Andy) Lee
- LAC + USC Medical Center, Los Angeles County Department of Health Service, Los Angeles, CA, USA
| | - Lalantha Leelarathna
- Manchester University NHS Foundation Trust and The University of Manchester, Manchester, UK
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital and University of Toronto, Toronto, ON, Canada
| | - Marcus Lind
- University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Umesh Masharani
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Viswanathan Mohan
- Dr. Mohan’s Diabetes Specialities Centre, Chennai, India
- Madras Diabetes Research Foundation, Chennai, India
| | | | | | | | | | | | | | - Moshe Phillip
- Institute for Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | | | - Gerry Rayman
- Ipswich Hospital, East Suffolk and North Essex Foundation Trust and University of East Anglia, Ipswich, UK
| | - Eun-Jung Rhee
- Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Steven J. Russell
- Massachusetts General Hospital Diabetes Research Center, Boston, MA, USA
| | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | | | - Koji Sode
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- North Carolina State University, Raleigh, NC, USA
| | | | | | - Kayo Waki
- The University of Tokyo, Tokyo, Japan
| | | | | | | | | | - Mihail Zilbermint
- Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Bethesda, MD, USA
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Tian T, Aaron RE, Yeung AM, Huang J, Drincic A, Seley JJ, Wallia A, Gilbert G, Spanakis EK, Masharani U, Faulds E, Hirsch IB, Dawood GE, Espinoza JC, Mendez CE, Kerr D, Klonoff DC. Use of Continuous Glucose Monitors in the Hospital: The Diabetes Technology Society Hospital Meeting Report 2023. J Diabetes Sci Technol 2023; 17:1392-1418. [PMID: 37559371 PMCID: PMC10563530 DOI: 10.1177/19322968231186575] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Abstract
The annual Virtual Hospital Diabetes Meeting was hosted by the Diabetes Technology Society on April 14 and 15, 2023, with the goal of reviewing the progress made in the hospital use of continuous glucose monitors (CGMs). Meeting topics included (1) Nursing Issues, Protocols, Order Sets, and Staff Education for Using CGMs, (2) Implementing CGM Programs for Use in the Wards, (3) Quality Metrics and Financial Implications of CGMs in the Hospital, (4) CGMs in the Critical Care Setting, (5) Special Situations: Labor/Delivery and Hemodialysis, (6) Research Session on CGMs in the Hospital, (7) Starting a CGM on Hospitalized Patients, (8) Automated Insulin Delivery Systems in the Hospital, (9) CGMs in Children, (10) Data Integration of CGMs for Inpatient Use and Telemetry, (11) Accuracy of CGMs/Comparison with Point-of-care Blood Glucose Testing, and (12) Discharge Planning with CGMs. Outcome data as well as shared collective real-life experiences were reviewed, and expert recommendations for CGM implementation were formulated.
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Affiliation(s)
- Tiffany Tian
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | | | - Amisha Wallia
- School of Medicine, Northwestern University Feinberg, Chicago, IL, USA
| | | | - Elias K. Spanakis
- Baltimore VA Medical Center and School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Umesh Masharani
- University of California San Francisco, San Francisco, CA, USA
| | - Eileen Faulds
- College of Nursing and Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Irl B. Hirsch
- University of Washington Medicine Diabetes Institute, Seattle, WA, USA
| | - Gigi E. Dawood
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Juan C. Espinoza
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | | | - David Kerr
- Diabetes Technology Society, Burlingame, CA, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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Niu I, Hsiao EC, Wustrack R, Wysolmerski JJ, Dann P, Masharani U. A Case of Hypercalcemia from PTHrP-Producing Fibromyxoid Sarcoma Responsive to Glucocorticoid Therapy. Calcif Tissue Int 2023; 113:246-253. [PMID: 37358786 PMCID: PMC10372127 DOI: 10.1007/s00223-023-01099-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/18/2023] [Indexed: 06/27/2023]
Abstract
The treatment of parathyroid hormone-related protein (PTHrP)-mediated hypercalcemia of malignancy includes treating the malignancy, intravenous fluids, and anti-resorptive therapies such as zoledronic acid or denosumab. PTHrP-mediated hypercalcemia has been reported in benign conditions such as systemic lupus erythematous (SLE) and sarcoidosis and appears to be responsive to glucocorticoids. We report a case of PTHrP-induced hypercalcemia due to a malignancy-low grade fibromyxoid sarcoma-that responded to glucocorticoid treatment. This is the first report of glucocorticoids controlling PTHrP-mediated hypercalcemia of malignancy. Immunohistochemistry of the surgical pathology localized PTHrP staining to the vascular endothelial cells within the tumor. Further studies are needed to elucidate the mechanism of glucocorticoid action in the treatment of PTHrP-mediated hypercalcemia of malignancy.
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Affiliation(s)
- Isabella Niu
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 400 Parnassus Ave., Suite A-550, San Francisco, CA, 94143, USA.
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 400 Parnassus Ave., Suite A-550, San Francisco, CA, 94143, USA
| | - Rosanna Wustrack
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 400 Parnassus Ave., Suite A-550, San Francisco, CA, 94143, USA
| | - John J Wysolmerski
- Division of Endocrinology and Metabolism, Department of Medicine, Yale School of Medicine, Yale University, TAC S141D, 300 Cedar Street, New Haven, CT, 06520-8020, USA
| | - Pamela Dann
- Division of Endocrinology and Metabolism, Department of Medicine, Yale School of Medicine, Yale University, TAC S141D, 300 Cedar Street, New Haven, CT, 06520-8020, USA
| | - Umesh Masharani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 400 Parnassus Ave., Suite A-550, San Francisco, CA, 94143, USA
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Huang J, Yeung AM, DuBord AY, Wolpert H, Jacobs PG, Lee WA, Drincic A, Spanakis EK, Sherr JL, Prahalad P, Fleming A, Hsiao VC, Kompala T, Lal RA, Fayfman M, Ginsberg BH, Galindo RJ, Stuhr A, Chase JG, Najafi B, Masharani U, Seley JJ, Klonoff DC. Diabetes Technology Meeting 2022. J Diabetes Sci Technol 2023; 17:1085-1120. [PMID: 36704821 PMCID: PMC10347991 DOI: 10.1177/19322968221148743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting from November 3 to November 5, 2022. Meeting topics included (1) the measurement of glucose, insulin, and ketones; (2) virtual diabetes care; (3) metrics for managing diabetes and predicting outcomes; (4) integration of continuous glucose monitor data into the electronic health record; (5) regulation of diabetes technology; (6) digital health to nudge behavior; (7) estimating carbohydrates; (8) fully automated insulin delivery systems; (9) hypoglycemia; (10) novel insulins; (11) insulin delivery; (12) on-body sensors; (13) continuous glucose monitoring; (14) diabetic foot ulcers; (15) the environmental impact of diabetes technology; and (16) spinal cord stimulation for painful diabetic neuropathy. A live demonstration of a device that can allow for the recycling of used insulin pens was also presented.
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Affiliation(s)
| | | | | | | | - Peter G. Jacobs
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Wei-An Lee
- Los Angeles County+University of Southern California Medical Center, Los Angeles, CA, USA
| | | | - Elias K. Spanakis
- Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
- Division of Endocrinology, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | | | - Tejaswi Kompala
- University of California, San Francisco, San Francisco, CA, USA
- Teladoc Health, Purchase, NY, USA
| | | | - Maya Fayfman
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | | | | | | | - Umesh Masharani
- University of California, San Francisco, San Francisco, CA, USA
| | | | - David C. Klonoff
- Diabetes Technology Society, Burlingame, CA, USA
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
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Wisel SA, Posselt AM, Szot GL, Nunez M, Santos-Parker K, Gardner JM, Worner G, Roll GR, Syed S, Kelly Y, Ward C, Tavakol M, Johnson K, Masharani U, Stock PG. A Multi-Modal Approach to Islet and Pancreas Transplantation With Calcineurin-Sparing Immunosuppression Maintains Long-Term Insulin Independence in Patients With Type I Diabetes. Transpl Int 2023; 36:11367. [PMID: 37359825 PMCID: PMC10285771 DOI: 10.3389/ti.2023.11367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023]
Abstract
Long-term success in beta-cell replacement remains limited by the toxic effects of calcineurin inhibitors (CNI) on beta-cells and renal function. We report a multi-modal approach including islet and pancreas-after-islet (PAI) transplant utilizing calcineurin-sparing immunosuppression. Ten consecutive non-uremic patients with Type 1 diabetes underwent islet transplant with immunosuppression based on belatacept (BELA; n = 5) or efalizumab (EFA; n = 5). Following islet failure, patients were considered for repeat islet infusion and/or PAI transplant. 70% of patients (four EFA, three BELA) maintained insulin independence at 10 years post-islet transplant, including four patients receiving a single islet infusion and three patients undergoing PAI transplant. 60% remain insulin independent at mean follow-up of 13.3 ± 1.1 years, including one patient 9 years after discontinuing all immunosuppression for adverse events, suggesting operational tolerance. All patients who underwent repeat islet transplant experienced graft failure. Overall, patients demonstrated preserved renal function, with a mild decrease in GFR from 76.5 ± 23.1 mL/min to 50.2 ± 27.1 mL/min (p = 0.192). Patients undergoing PAI showed the greatest degree of renal impairment following initiation of CNI (56% ± 18.7% decrease in GFR). In our series, repeat islet transplant is ineffective at maintaining long-term insulin independence. PAI results in durable insulin independence but is associated with impaired renal function secondary to CNI dependence.
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Affiliation(s)
- Steven A. Wisel
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Andrew M. Posselt
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Gregory L. Szot
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Miguel Nunez
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Keli Santos-Parker
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - James M. Gardner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Giulia Worner
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Garrett R. Roll
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Shareef Syed
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Yvonne Kelly
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Casey Ward
- Department of Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Medhi Tavakol
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Kristina Johnson
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
| | - Umesh Masharani
- Division of Endocrinology, University of California, San Francisco, San Francisco, CA, United States
| | - Peter G. Stock
- Division of Transplantation, University of California, San Francisco, San Francisco, CA, United States
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9
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Rodriguez-Valadez JM, Tahsin M, Fleischmann KE, Masharani U, Yeboah J, Park M, Li L, Weber E, Li Y, Berkalieva A, Max W, Hunink MM, Ferket BS. Cardiovascular and Renal Benefits of Novel Diabetes Drugs by Baseline Cardiovascular Risk: A Systematic Review, Meta-analysis, and Meta-regression. Diabetes Care 2023; 46:1300-1310. [PMID: 37220263 PMCID: PMC10234755 DOI: 10.2337/dc22-0772] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 02/27/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Eligibility for glucagon-like peptide 1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) has been expanded to patients with diabetes at lower cardiovascular risk, but whether treatment benefits differ by risk levels is not clear. PURPOSE To investigate whether patients with varying risks differ in cardiovascular and renal benefits from GLP-1RA and SGLT2i with use of meta-analysis and meta-regression. DATA SOURCES We performed a systematic review using PubMed through 7 November 2022. STUDY SELECTION We included reports of GLP-1RA and SGLT2i confirmatory randomized trials in adult patients with safety or efficacy end point data. DATA EXTRACTION Hazard ratio (HR) and event rate data were extracted for mortality, cardiovascular, and renal outcomes. DATA SYNTHESIS We analyzed 9 GLP-1RA and 13 SGLT2i trials comprising 154,649 patients. Summary HRs were significant for cardiovascular mortality (GLP-1RA 0.87 and SGLT2i 0.86), major adverse cardiovascular events (0.87 and 0.88), heart failure (0.89 and 0.70), and renal (0.84 and 0.65) outcomes. For stroke, efficacy was significant for GLP-1RA (0.84) but not for SGLT2i (0.92). Associations between control arm cardiovascular mortality rates and HRs were nonsignificant. Five-year absolute risk reductions (0.80-4.25%) increased to 11.6% for heart failure in SGLT2i trials in patients with high risk (Pslope < 0.001). For GLP1-RAs, associations were nonsignificant. LIMITATIONS Analyses were limited by lack of patient-level data, consistency in end point definitions, and variation in cardiovascular mortality rates for GLP-1RA trials. CONCLUSIONS Relative effects of novel diabetes drugs are preserved across baseline cardiovascular risk, whereas absolute benefits increase at higher risks, particularly regarding heart failure. Our findings suggest a need for baseline risk assessment tools to identify variation in absolute treatment benefits and improve decision-making.
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Affiliation(s)
- José M. Rodriguez-Valadez
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Malak Tahsin
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kirsten E. Fleischmann
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, CA
| | - Joseph Yeboah
- Section of Cardiovascular Medicine, Internal Medicine, Wake Forest University School of Medicine, Winston Salem, NC
| | - Meyeon Park
- Department of Medicine, University of California, San Francisco, CA
| | - Lihua Li
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ellerie Weber
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yan Li
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Asem Berkalieva
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California, San Francisco, CA
| | - M.G. Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Bart S. Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
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10
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Rodriguez Valadez JM, Tahsin M, Masharani U, Park M, Hunink MM, Yeboah J, Li L, Weber E, Li Y, Berkalieva A, Avezaat L, Max W, Fleischmann KE, Ferket BS. Abstract P140: Potential Mediators for Cardiovascular Benefits of Novel Diabetes Medications: A Meta-Regression Analysis. Circulation 2023. [DOI: 10.1161/circ.147.suppl_1.p140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
Background:
Prior research suggests cardiovascular (CV) benefits of glucose-lowering interventions may be mediated by changes in hemoglobin A1c (HbA1c), bodyweight, systolic blood pressure (SBP), hematocrit, and urine albumin-creatinine ratio (uACR). We evaluated the heterogeneity of CV benefits by these potential mediators for sodium-glucose transporter 2 inhibitors (SGLT2i) and glucagon-like peptide 1 receptor agonists (GLP-1RAs) using a meta-analytic approach.
Methods:
We performed a systematic review and meta-regression analyses of 12 SGLT2i and 9 GLP-1RA CV outcome trials using linear mixed models of treatment efficacy measured as log hazard ratios (HRs) vs changes in potential mediators. We extracted follow-up mediator data for treatment and control, preferably at 12 months post randomization. Outcomes included MI, stroke, and MACE (a composite of MI, stroke, or CV death). We investigated slope differences between drug classes using interaction terms and likelihood-ratio tests.
Results:
Treatment efficacy for MACE improved with more HbA1c reduction among GLP-1RA (slope .26; P
slope
.02) but not among SGLT2i trials (slope -.22; P
slope
.39; P
interaction
.06), see
Figure
. Treatment efficacy for MACE, MI, and stroke decreased with more weight loss for SGLT2i (slope –.17, –.29, –.39; P
slope
<.05) but not for GLP-1RA trials (slope .05, .03, .07; P
slope
.30, .62, .32). Slopes differed significantly between drug classes: P
interaction
<.05. For stroke, we observed a trend of less treatment efficacy with increases in hematocrit among five SGLT2i trials with available data (slope .96; P
slope
.07). We did not find any indication of mediation effects by SBP and uACR for SGLT2i or GLP-1RAs (slopes -.11 -.07; P
slopes
≥ .05).
Conclusion:
We confirm previous findings of increased CV benefits with reductions in HbA1c for GLP1-RAs. Further research is needed to investigate the potential loss of SGLT2i efficacy with greater weight loss and increase in hematocrit.
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Affiliation(s)
| | | | | | | | | | | | - Lihua Li
- Icahn Sch of Medicine at MtSinai, NYC, NY
| | | | - Yan Li
- Icahn Sch of Medicine at MtSinai, New York, NY
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11
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Quandt Z, Kim S, Villanueva-Meyer J, Coupe C, Young A, Kang JH, Yazdany J, Schmajuk G, Rush S, Ziv E, Perdigoto AL, Herold K, Lechner MG, Su MA, Tyrrell JB, Bluestone J, Anderson M, Masharani U. Spectrum of Clinical Presentations, Imaging Findings, and HLA Types in Immune Checkpoint Inhibitor-Induced Hypophysitis. J Endocr Soc 2023; 7:bvad012. [PMID: 36860908 PMCID: PMC9969737 DOI: 10.1210/jendso/bvad012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Indexed: 02/09/2023] Open
Abstract
Context Hypophysitis is a known immune-related adverse event (irAE) of immune checkpoint inhibitors (CPIs), commonly associated with CTLA-4 inhibitors and less often with PD-1/PD-L1 inhibitors. Objective We aimed to determine clinical, imaging, and HLA characteristics of CPI-induced hypophysitis (CPI-hypophysitis). Methods We examined the clinical and biochemical characteristics, magnetic resonance imaging (MRI) of the pituitary, and association with HLA type in patients with CPI-hypophysitis. Results Forty-nine patients were identified. Mean age was 61.3 years, 61.2% were men, 81.6% were Caucasian, 38.8% had melanoma, and 44.5% received PD-1/PD-L1 inhibitor monotherapy while the remainder received CTLA-4 inhibitor monotherapy or CTLA-4/PD-1 inhibitor combination therapy. A comparison of CTLA-4 inhibitor exposure vs PD-1/PD-L1 inhibitor monotherapy revealed faster time to CPI-hypophysitis (median 84 vs 185 days, P < .01) and abnormal pituitary appearance on MRI (odds ratio 7.00, P = .03). We observed effect modification by sex in the association between CPI type and time to CPI-hypophysitis. In particular, anti-CTLA-4 exposed men had a shorter time to onset than women. MRI changes of the pituitary were most common at the time of hypophysitis diagnosis (55.6% enlarged, 37.0% normal, 7.4% empty or partially empty) but persisted in follow-up (23.8% enlarged, 57.1% normal, 19.1% empty or partially empty). HLA typing was done on 55 subjects; HLA type DQ0602 was over-represented in CPI-hypophysitis relative to the Caucasian American population (39.4% vs 21.5%, P = 0.01) and CPI population. Conclusion The association of CPI-hypophysitis with HLA DQ0602 suggests a genetic risk for its development. The clinical phenotype of hypophysitis appears heterogenous, with differences in timing of onset, changes in thyroid function tests, MRI changes, and possibly sex related to CPI type. These factors may play an important role in our mechanistic understanding of CPI-hypophysitis.
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Affiliation(s)
- Zoe Quandt
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Stephanie Kim
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Javier Villanueva-Meyer
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Catherine Coupe
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Arabella Young
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
- Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, UT 84112, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Jee Hye Kang
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
- Division of Rheumatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
- Division of Rheumatology, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Division of Rheumatology, Department of Medicine, San Francisco VA Medical Center, San Francisco, CA 94121, USA
- Philip R. Lee Institute for Health Policy Studies, San Francisco, CA 94158, USA
| | - Stephanie Rush
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Elad Ziv
- Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Ana Luisa Perdigoto
- Department of Immunobiology, Yale University, New Haven, CT 06520, USA
- Department of Internal Medicine, Yale University, New Haven, CT 06520, USA
- Division of Endocrinology and Metabolism, Department of Medicine, Yale University, New Haven, CT 06520, USA
| | - Kevan Herold
- Department of Immunobiology, Yale University, New Haven, CT 06520, USA
- Department of Internal Medicine, Yale University, New Haven, CT 06520, USA
- Division of Endocrinology and Metabolism, Department of Medicine, Yale University, New Haven, CT 06520, USA
| | - Melissa G Lechner
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, CA 90095, USA
| | - Maureen A Su
- Department of Microbiology, Immunology, and Medical Genetics, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
- Department of Pediatrics, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
| | - J Blake Tyrrell
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Jeffrey Bluestone
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Mark Anderson
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, CA 94122, USA
- Diabetes Center, University of California, San Francisco, San Francisco, CA 94122, USA
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12
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Niu I, Hsiao E, Wustrack R, Wysolmerski J, Dann P, Masharani U. PSAT208 A Case of Hypercalcemia From PTHrP-Producing Fibromyxoid Sarcoma Responsive to Glucocorticoid Therapy. J Endocr Soc 2022. [DOI: 10.1210/jendso/bvac150.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Parathyroid hormone-related protein (PTHrP) is a major cause of humoral hypercalcemia of malignancy. PTHrP-induced hypercalcemia can also occur in benign disorders including pneumonia, SLE, HIV, sarcoidosis, and mammary hyperplasia. Treatment for PTHrP-induced hypercalcemia includes treating the underlying disorder and general management of hypercalcemia.
Clinical Case
A 70-year-old male with a chronic left thigh mass following trauma 12 years prior diagnosed as myositis ossificans, presented with worsening pain and swelling over the mass. Evaluation revealed serum calcium 18.6 mg/dl, PTH 10 ng/L (18-90), 25(OH)D 7 ng/ml (20-50), 1,25(OH)2D 15 pg/ml (20-79), PTHrP 9.3 pmol/L (≤ 4.2), negative SPEP, UPEP, serum light chains and immunofixation, and no bony lesions. MRI showed a large heterogenous mass centered in the left adductor muscle compatible with chronic hematoma with myositis ossificans. FDG PET/CT scan showed FDG avidity and calcification of the left thigh without any other site of uptake. Combination of IV hydration, denosumab and zoledronic acid lowered his calcium to 9.5 mg/dl, but levels increased again within 10 days. Repeated treatments with zoledronic acid initially led to modest lowering of calcium to 10.5 mg/dl, but he became refractory to treatment after 6 weeks, with calcium increasing to 12.3 mg/dl.Two biopsies of the mass were performed, including an open biopsy. The pathology showed nonpolarizable crystalline material with foreign giant cell reaction, without evidence for malignancy. It was concluded therefore that the patient's PTHrP-induced hypercalcemia was secondary to an inflammatory granulomatous condition. Since it had been reported that PTHrP-induced hypercalcemia in SLE and sarcoidosis responded to glucocorticoids, we initiated treatment with methylprednisolone 24 mg daily. After 7 days, the calcium declined from 12.3 to 10.5 mg/dl and PTHrP declined to 2.5 pmol/L. When the methylprednisolone dose was reduced to 12 mg daily, calcium increased to 11.4 mg/dl and PTHrP to 5 pmol/L. Increasing the methylprednisolone briefly back to 24 mg daily, and then 20 mg daily, lowered calcium to 9.0 mg/dl, increased PTH to 74 ng/L, and normalized PTHrP to 1.3 pmol/L. As long-term management with high-dose steroids was not a tenable option, a decision was made to resect the mass. The pathological diagnosis of the surgical mass was low-grade fibromyxoid sarcoma (LGFMS). Immunohistochemical studies identified PTHrP in surrounding vasculature, suggesting possible tumor-vessel interaction.
Conclusion
PTHrP-mediated hypercalcemia is rarely seen in sarcomas and treatments include coadministration of bisphosphonates, chemotherapy and surgery. We report here the first case of PTHrP-induced hypercalcemia from LGFMS with sustained lowering of calcium and PTHrP levels with glucocorticoid treatment. Further studies are needed to elucidate the mechanism of glucocorticoids in the treatment of PTHrP-induced hypercalcemia and could include lowering levels of inflammatory cytokines that stimulate PTHrP production from tumor cells, or by directly suppressing PTHrP gene expression.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
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13
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Babey M, Hsiao V, Masharani U, Shey S, Mehta P, Koh E. ODP162 Assessing Emergency Preparedness in Patients with Type 1 Diabetes at a Single Academic Institution During the COVID-19 Pandemic. J Endocr Soc 2022. [PMCID: PMC9624667 DOI: 10.1210/jendso/bvac150.617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background After natural disasters, patients with diabetes (DM) have been shown to have increases in hemoglobin A1c levels and emergency room visits for hypoglycemic and hyperglycemic emergencies. Early in the COVID-19 pandemic, DM medication refills decreased and patients indicated challenges with accessing outpatient insulin and supplies. In response, the Diabetes Disaster Response Coalition recommended that patients have a DM emergency preparedness plan in place. In our type 1 diabetes (T1D) clinic, no standardized protocol existed to determine whether patients had an emergency plan. We created a voluntary 3-question survey for patients to complete which would prompt providers to address medication deficiencies and provide education on what to do in setting of pump failure. Objectives Implementation of a standardized survey to assess DM emergency preparedness during clinic visits will reveal and address medication and patient knowledge gaps. At least 50% of patients seen in the T1D clinic will complete the survey during the intervention period Methods: We designed our intervention with consideration for clinic workflow and provider and patient ease of use. The pilot intervention period was from November 2020 to May 2021. Data was collected on survey completion and measures performed by the clinician to address medication and pump knowledge deficiencies. Our intervention steps are outlined below: Prior to the visit, patients received a secure message with a 3-question survey asking whether they had an emergency kit, 2 weeks of medications and supplies, and for patients on an insulin pump, whether they felt comfortable transitioning from pump to basal-bolus regimen. Clinicians were notified of which patients were eligible to complete the survey. During the visit, clinicians reviewed completed surveys, prescribed medications and supplies, and educated patients on approaching pump failure if applicable. Patients were provided a handout with an emergency supply checklist and insulin storage tips. Results Over the intervention period, 212 patients received the survey. Of these, 129 (60.8%) completed and discussed survey answers with their endocrinologist. 54.3% of these patients did not have an emergency kit and 48.8% did not have at least 2 weeks of supplies. Additionally, 43.4% were prescribed medications and diabetes equipment during the clinic visit, the most common being basal insulin and glucagon. Of the 79 patients using an insulin pump, 44.3% did not know how to independently transition to a basal-bolus regimen and were provided education during the visit. Conclusions Our intervention assessed and addressed important gaps in emergency preparedness in our patients with T1D. Over half of participants did not have an emergency kit, and many needed additional prescriptions and education on approaching DM emergency situations. Similar interventions should be pursued for all patients with DM to prevent psychological stress, morbidity, and mortality during future natural disasters. Presentation: No date and time listed
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14
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Huang J, Yeung AM, Nguyen KT, Xu NY, Preiser JC, Rushakoff RJ, Seley JJ, Umpierrez GE, Wallia A, Drincic AT, Gianchandani R, Lansang MC, Masharani U, Mathioudakis N, Pasquel FJ, Schmidt S, Shah VN, Spanakis EK, Stuhr A, Treiber GM, Klonoff DC. Hospital Diabetes Meeting 2022. J Diabetes Sci Technol 2022; 16:1309-1337. [PMID: 35904143 PMCID: PMC9445340 DOI: 10.1177/19322968221110878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The annual Virtual Hospital Diabetes Meeting was hosted by Diabetes Technology Society on April 1 and April 2, 2022. This meeting brought together experts in diabetes technology to discuss various new developments in the field of managing diabetes in hospitalized patients. Meeting topics included (1) digital health and the hospital, (2) blood glucose targets, (3) software for inpatient diabetes, (4) surgery, (5) transitions, (6) coronavirus disease and diabetes in the hospital, (7) drugs for diabetes, (8) continuous glucose monitoring, (9) quality improvement, (10) diabetes care and educatinon, and (11) uniting people, process, and technology to achieve optimal glycemic management. This meeting covered new technology that will enable better care of people with diabetes if they are hospitalized.
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Affiliation(s)
| | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | - Amisha Wallia
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Umesh Masharani
- University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | | | | | | | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Diabetes Research Institute, Mills-Peninsula Medical Center, 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
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15
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Xu NY, Nguyen KT, DuBord AY, Pickup J, Sherr JL, Teymourian H, Cengiz E, Ginsberg BH, Cobelli C, Ahn D, Bellazzi R, Bequette BW, Gandrud Pickett L, Parks L, Spanakis EK, Masharani U, Akturk HK, Melish JS, Kim S, Kang GE, Klonoff DC. Diabetes Technology Meeting 2021. J Diabetes Sci Technol 2022; 16:1016-1056. [PMID: 35499170 PMCID: PMC9264449 DOI: 10.1177/19322968221090279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 4 to November 6, 2021. This meeting brought together speakers to discuss various developments within the field of diabetes technology. Meeting topics included blood glucose monitoring, continuous glucose monitoring, novel sensors, direct-to-consumer telehealth, metrics for glycemia, software for diabetes, regulation of diabetes technology, diabetes data science, artificial pancreas, novel insulins, insulin delivery, skin trauma, metabesity, precision diabetes, diversity in diabetes technology, use of diabetes technology in pregnancy, and green diabetes. A live demonstration on a mobile app to monitor diabetic foot wounds was presented.
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Affiliation(s)
- Nicole Y. Xu
- Diabetes Technology Society,
Burlingame, CA, USA
| | | | | | | | | | | | - Eda Cengiz
- University of California, San
Francisco, San Francisco, CA, USA
| | | | | | - David Ahn
- Mary & Dick Allen Diabetes Center
at Hoag, Newport Beach, CA, USA
| | | | | | | | - Linda Parks
- University of California, San
Francisco, San Francisco, CA, USA
| | - Elias K. Spanakis
- Baltimore VA Medical Center,
Baltimore, MD, USA
- University of Maryland, Baltimore,
MD, USA
| | - Umesh Masharani
- University of California, San
Francisco, San Francisco, CA, USA
| | - Halis K. Akturk
- Barbara Davis Center for Diabetes,
University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Sarah Kim
- University of California, San
Francisco, San Francisco, CA, USA
| | - Gu Eon Kang
- The University of Texas at Dallas,
Richardson, TX, USA
| | - David C. Klonoff
- Diabetes Research Institute,
Mills-Peninsula Medical Center, San Mateo, CA, USA
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16
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Masharani U, Strycker LA, Fisher L. The ubiquity of diabetes distress among adults with type 1 diabetes in an urban, academic practice: A template for intervention. Diabet Med 2022; 39:e14832. [PMID: 35322466 DOI: 10.1111/dme.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/22/2022] [Indexed: 11/29/2022]
Abstract
AIMS The aim of this study was to assess the patterns of diabetes distress within an urban, technology-oriented academic clinical practice to inform staff training and intervention. METHODS Adults with type 1 diabetes completed the Type 1 Diabetes Distress Scale at their regular clinic visit. Descriptive statistics were generated to document the prevalence of diabetes distress overall, and from seven primary sources of distress: powerlessness, disease management, hypoglycaemia, negative social perceptions, eating, physician and family/friends. Additional analyses explored relations between diabetes distress, demographic characteristics and disease status. RESULTS The prevalence of elevated diabetes distress was 30% overall, with 88% of the sample reporting elevated distress from at least one primary source. Women reported more elevated distress overall, and from the primary sources. There was an inverse relationship between diabetes duration with total diabetes distress (r = -0.19) and with the powerlessness subscale (r = -0.28). Also, those without micro- and/or macrovascular complications more frequently reported elevated distress from powerlessness (85%) compared to those having complications (61%). Use of technology (continuous glucose monitoring, insulin pumps) was not significantly related to diabetes distress. Diabetes distress was positively correlated with HbA1c. About 22% of individuals with HbA1c <53 mmol/mol (<7%) had elevated total distress. About a third of the sample (34%-39%) reported elevated distress from powerlessness, hypoglycaemia, negative social perceptions, eating, or family/friends. CONCLUSIONS It is critical to understand clinic-specific patterns of diabetes distress in order to customise staff training and intervention programmes, and thereby reduce distress among unique populations of adults with type 1 diabetes in different settings.
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Affiliation(s)
- Umesh Masharani
- Department of Medicine, University of California, San Francisco, California, USA
| | | | - Lawrence Fisher
- Department of Family Medicine, University of California, San Francisco, California, USA
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17
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Abstract
AIMS The study examined the prevalence and degree of lactate elevation in diabetic ketoacidosis, and explored which biochemical abnormalities predicted L-lactate levels. METHODS We reviewed episodes of diabetic ketoacidosis from 79 diabetes patients (one episode per patient). Separate univariate linear regression models were specified to predict lactate level from each of nine biochemical variables. Significant predictors from the univariate models were included in a final multivariate linear regression model to predict lactate levels. RESULTS Mean (SD) lactate level was 3.05 (1.66) mmol/L; about 65% of patients had lactate levels >2 mmol/L. In the final multivariate linear regression model (R2 = 0.45), higher lactate levels were associated with greater hydrogen ion concentration (standardised β = .60, t = 4.16, p < 0.0001), higher blood glucose (standardised β = .28, t = 2.67, p = 0.009) and lower glomerular filtration rate estimated from creatinine (standardised β = -.23, t = 2.29, p = 0.025). Bicarbonate, beta-hydroxybutyrate, body mass index, mean arterial pressure and calculated osmolality were not significant predictors of lactate level. There were three distinct patterns of lactate levels with treatment of diabetic ketoacidosis: group 1 = gradual decline, group 2 = initial increase and then decline and group 3 = initial decline followed by a transient peak and subsequent decline. CONCLUSIONS Elevated lactate level is the norm in patients with diabetic ketoacidosis. Higher blood glucose levels and higher hydrogen ion concentrations are related to greater lactate. With treatment, there are different patterns of decline in lactate levels.
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Affiliation(s)
- Umesh Masharani
- Department of Medicine, University of California, San Francisco, California, USA
| | | | - Ann A Lazar
- Division of Biostatistics, University of California, San Francisco, California, USA
| | - Karin Wu
- Department of Medicine, University of California, San Francisco, California, USA
| | - George A Brooks
- Department of Integrative Biology, University of California, Berkeley, California, USA
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18
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Ferket BS, Hunink MM, Masharani U, Max W, Yeboah J, Burke GL, Fleischmann KE. Lifetime Cardiovascular Disease Risk by Coronary Artery Calcium Score in Individuals With and Without Diabetes: An Analysis From the Multi-Ethnic Study of Atherosclerosis. Diabetes Care 2022; 45:975-982. [PMID: 35168253 PMCID: PMC9114718 DOI: 10.2337/dc21-1607] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/24/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess lifetime cardiovascular disease (CVD) risk by coronary artery calcium (CAC) score in individuals with diabetes from the Multi-Ethnic Study of Atherosclerosis (MESA) and compare risk with that in individuals without diabetes. RESEARCH DESIGN AND METHODS We developed a microsimulation model with well, diabetes, post-CVD, and death health states using multivariable time-dependent Cox regression with age as time scale. We initially used 10-year follow-up data of 6,769 MESA participants, including coronary heart disease (CHD) (n = 272), heart failure (n = 201), stroke (n = 186), and competing death (n = 619) and assessed predictive validity at 15 years. We externally validated the model in matched National Health and Nutrition Examination Survey (NHANES) participants. Subsequently, we predicted CVD risk until age 100 years by diabetes, 10-year pooled cohort equations risk, and CAC score category (0, 1-100, or 100+). RESULTS The model showed good calibration and discriminative performance at 15 years, with discrimination indices 0.71-0.78 across outcomes. In the NHANES cohort, predicted 15-year mortality risk corresponded well with Kaplan-Meier risk, especially for those with diabetes: 29.6% (95% CI 24.9-34.8) vs. 32.4% (95% CI 27.2-37.2), respectively. Diabetes increased lifetime CVD risk, similar to shifting one CAC category upward (from 0 to 1-100 or from 1-100 to 100+). Patients with diabetes and CAC score of 0 had a lifetime CVD risk that overlapped with that of individuals without diabetes who were at low 10-year pooled cohort equations risk (<7.5%). CONCLUSIONS Patients with diabetes carry a spectrum of CVD risk. CAC scoring may improve decisions for preventive interventions for patients with diabetes by better delineating lifetime CVD risk.
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Affiliation(s)
- Bart S. Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M.G. Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands
- Center for Health Decision Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Umesh Masharani
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA
| | - Joseph Yeboah
- Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston Salem, NC
| | - Gregory L. Burke
- Division of Public Health, Wake Forest School of Medicine, Winston Salem, NC
| | - Kirsten E. Fleischmann
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA
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19
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Thiruvengadam NR, Forde KA, Miranda J, Kim C, Behr S, Masharani U, Arain MA. Disconnected Pancreatic Duct Syndrome: Pancreatitis of the Disconnected Pancreas and Its Role in the Development of Diabetes Mellitus. Clin Transl Gastroenterol 2022; 13:e00457. [PMID: 35060942 PMCID: PMC8865505 DOI: 10.14309/ctg.0000000000000457] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 12/28/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Disconnected pancreatic duct syndrome (DPDS) is a recognized complication of necrotizing pancreatitis (NP). Manifestations include recurrent peripancreatic fluid collections (R-PFC) and pancreatocutaneous fistulae (PC-Fistulae). Pancreatitis of the disconnected pancreatic segment (DPDS-P) and its relationship to new-onset diabetes after pancreatitis (NODAP) are not well characterized. METHODS We performed a retrospective cohort study of consecutive patients with NP admitted to University of California, San Francisco from January 2011 to June 2019. A diagnosis of a disconnected pancreatic duct (PD) was confirmed using computed tomography and magnetic resonance cholangiopancreatography/endoscopic retrograde cholangiopancreatography. DPDS was defined as a disconnected PD presenting with R-PFC, PC-Fistulae, or DPDS-P. The primary outcome was NODAP, defined as diabetes mellitus (DM) occurring >3 months after NP. Cox proportional hazards regression was used to evaluate the relationship between DPDS and NODAP. RESULTS Of 171 patients with NP in this study, the mean clinical follow-up was 46 ± 18 months and the imaging follow-up was 38 ± 20 months. Twenty-seven patients (16%) developed DPDS-P at a median of 28 months. New-onset DM occurred in 54 of the 148 patients (36%), with 22% developing DM within 3 months of NP and 14% developing NODAP at a median of 31 months after AP. DPDS-P was associated with NODAP when compared with non-DPDS patients (adjusted hazard ratio 5.63 95% confidence interval: 1.69-18.74, P = 0.005) while R-PFCs and PC-Fistulae were not. DISCUSSION DPDS and NODAP occurred in 28% and 14% of the patients, respectively. Pancreatitis of the disconnected pancreas occurred in 16% of the patients and was associated with higher rates of NODAP when compared with patients with other manifestations of DPDS and patients without DPDS.
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Affiliation(s)
- Nikhil R. Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University School of Medicine, Loma Linda, California, USA;
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA;
- Center for Endoscopic Innovation, Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA;
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
| | - Kimberly A. Forde
- Division of Gastroenterology and Hepatology, Temple University, Philadelphia, Pennsylvania
| | - Janille Miranda
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
| | - Christopher Kim
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA;
| | - Spencer Behr
- Abdominal Imaging Section, Department of Radiology, University of California San Francisco, San Francisco, California, USA;
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, Department of Medicine, The University of California, San Francisco, California, USA.
| | - Mustafa A. Arain
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, California, USA;
- Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.
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20
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Rugo HS, Lacouture ME, Goncalves MD, Masharani U, Aapro MS, O'Shaughnessy JA. A multidisciplinary approach to optimizing care of patients treated with alpelisib. Breast 2022; 61:156-167. [PMID: 35016012 PMCID: PMC8749445 DOI: 10.1016/j.breast.2021.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/23/2021] [Accepted: 12/26/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE The oral, α-specific phosphatidylinositol-3-kinase (PI3Kα) inhibitor alpelisib is the first PI3K inhibitor approved for the treatment of advanced breast cancer. As alpelisib is a relatively new therapeutic option, specific guidance and a multidisciplinary approach are needed to provide optimal patient care. The primary objective of this manuscript is to provide comprehensive guidance on minimizing and managing adverse events (AEs) for patients with advanced breast cancer who are receiving alpelisib. METHODS Clinical studies, prescribing information, published literature, and relevant guidelines were reviewed to provide recommendations on the prevention and management of alpelisib-associated AEs. RESULTS The most common AEs associated with alpelisib in the phase 3 SOLAR-1 trial were hyperglycemia and rash (which are considered on-target effects of PI3Kα inhibition) and gastrointestinal AEs, including diarrhea, nausea, and decreased appetite. These AEs require regular monitoring, early recognition, and prompt initiation of appropriate treatment. In addition, there are effective strategies to reduce the onset and severity of frequently observed AEs-in particular, onset of hyperglycemia and rash may be reduced by lifestyle changes (such as reduced intake of carbohydrates and regular exercise) and antihistamine prophylaxis, respectively. To reduce risk of severe hyperglycemia, it is essential to achieve adequate glycemic control prior to initiation of alpelisib treatment. CONCLUSION Overall, alpelisib-associated AEs are generally manageable with prompt recognition, regular monitoring, and appropriate intervention, preferably with a multidisciplinary approach.
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Affiliation(s)
- Hope S Rugo
- Department of Medicine (Hematology/Oncology), University of California San Francisco Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA.
| | - Mario E Lacouture
- Dermatology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Marcus D Goncalves
- Division of Endocrinology, Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Umesh Masharani
- Department of Medicine (Endocrinology), University of California San Francisco, San Francisco, CA, USA.
| | - Matti S Aapro
- Department of Oncology, Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland.
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21
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Shang T, Zhang JY, Bequette BW, Raymond JK, Coté G, Sherr JL, Castle J, Pickup J, Pavlovic Y, Espinoza J, Messer LH, Heise T, Mendez CE, Kim S, Ginsberg BH, Masharani U, Galindo RJ, Klonoff DC. Diabetes Technology Meeting 2020. J Diabetes Sci Technol 2021; 15:916-960. [PMID: 34196228 PMCID: PMC8258529 DOI: 10.1177/19322968211016480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 12 to November 14, 2020. This meeting brought together speakers to cover various perspectives about the field of diabetes technology. The meeting topics included artificial intelligence, digital health, telemedicine, glucose monitoring, regulatory trends, metrics for expressing glycemia, pharmaceuticals, automated insulin delivery systems, novel insulins, metrics for diabetes monitoring, and discriminatory aspects of diabetes technology. A live demonstration was presented.
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Affiliation(s)
- Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | - Jennifer K. Raymond
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Gerard Coté
- Texas A & M University, College Station, Texas, USA
| | | | | | | | | | - Juan Espinoza
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Sarah Kim
- University of California San Francisco, San Francisco, CA, USA
| | | | - Umesh Masharani
- University of California San Francisco, San Francisco, CA, USA
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22
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Ferket BS, Hunink MGM, Masharani U, Max W, Yeboah J, Fleischmann KE. Long-term Predictions of Incident Coronary Artery Calcium to 85 Years of Age for Asymptomatic Individuals With and Without Type 2 Diabetes. Diabetes Care 2021; 44:1664-1671. [PMID: 34078663 DOI: 10.2337/dc20-1960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the utility of repeated computed tomography (CT) coronary artery calcium (CAC) testing, we assessed risks of detectable CAC and its cardiovascular consequences in individuals with and without type 2 diabetes ages 45-85 years. RESEARCH DESIGN AND METHODS We included 5,836 individuals (618 with type 2 diabetes, 2,972 without baseline CAC) from the Multi-Ethnic Study of Atherosclerosis. With logistic and Cox regression we evaluated the impact of type 2 diabetes, diabetes treatment duration, and other predictors on prevalent and incident CAC. We used time-dependent Cox modeling of follow-up data (median 15.9 years) for two repeat CT exams and cardiovascular events to assess the association of CAC at follow-up CT with cardiovascular events. RESULTS For 45 year olds with type 2 diabetes, the likelihood of CAC at baseline was 23% vs. 17% for those without. Median age at incident CAC was 52.2 vs. 62.3 years for those with and without diabetes, respectively. Each 5 years of diabetes treatment increased the odds and hazard rate of CAC by 19% (95% CI 8-33) and 22% (95% CI 6-41). Male sex, White ethnicity/race, hypertension, hypercholesterolemia, obesity, and low serum creatinine also increased CAC. CAC at follow-up CT independently increased coronary heart disease rates. CONCLUSIONS We estimated cumulative CAC incidence to age 85 years. Patients with type 2 diabetes develop CAC at a younger age than those without diabetes. Because incident CAC is associated with increased coronary heart disease risk, the value of periodic CAC-based risk assessment in type 2 diabetes should be evaluated.
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Affiliation(s)
- Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - M G Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands.,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
| | - Umesh Masharani
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Wendy Max
- Institute for Health & Aging and Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, CA
| | - Joseph Yeboah
- Heart and Vascular Center of Excellence, Wake Forest Baptist Health, Winston Salem, NC
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23
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Morey JR, Jiang S, Klein S, Max W, Masharani U, Fleischmann KE, Hunink MGM, Ferket BS. Estimating Long-Term Health Utility Scores and Expenditures for Cardiovascular Disease From the Medical Expenditure Panel Survey. Circ Cardiovasc Qual Outcomes 2021; 14:e006769. [PMID: 33761758 DOI: 10.1161/circoutcomes.120.006769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Long-term health utility scores and costs used in cost-effectiveness analyses of cardiovascular disease prevention and management can be inconsistent, outdated, or invalid for the diverse population of the United States. Our aim was to develop a user friendly, standardized, publicly available code and catalog to derive more valid long-term values for health utility and expenditures following cardiovascular disease events. METHODS Individual-level Short Form-12 version 2 health-related quality of life and expenditure data were obtained from the pooled 2011 to 2016 Medical Expenditure Panel Surveys. We developed code using the R programming language to estimate preference-weighted Short Form-6D utility scores from the Short Form-12 for quality-adjusted life year calculations and predict annual health care expenditures. Result predictors included cardiovascular disease diagnosis (myocardial infarction, ischemic stroke, heart failure, cardiac dysrhythmias, angina pectoris, and peripheral artery disease), sociodemographic factors, and comorbidity variables. RESULTS The cardiovascular disease diagnoses with the lowest utility scores were heart failure (0.635 [95% CI, 0.615-0.655]), angina pectoris (0.649 [95% CI, 0.630-0.667]), and ischemic stroke (0.649 [95% CI, 0.635-0.663]). The highest annual expenditures were for heart failure ($20 764 [95% CI, $17 500-$24 027]), angina pectoris ($18 428 [95% CI, $16 102-$20 754]), and ischemic stroke ($16 925 [95% CI, $15 672-$20 616]). CONCLUSIONS The developed code and catalog may improve the quality and comparability of cost-effectiveness analyses by providing standardized methods for extracting long-term health utility scores and expenditures from Medical Expenditure Panel Survey data, which are more current and representative of the US population than previous sources.
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Affiliation(s)
- Jacob R Morey
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
| | - Shangqing Jiang
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington, Seattle (S.J.)
| | - Sharon Klein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, East Garden City, NY (S.K.)
| | - Wendy Max
- Institute for Health and Aging and Department of Social and Behavioral Sciences (W.M.), University of California, San Francisco
| | - Umesh Masharani
- Department of Medicine (U.M., K.E.F.), University of California, San Francisco
| | | | - M G Myriam Hunink
- Departments of Epidemiology and Radiology, Erasmus MC, Rotterdam, the Netherlands (M.G.M.H.).,Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA (M.G.M.H.)
| | - Bart S Ferket
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (J.R.M., B.S.F.)
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24
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Neinstein AB, Masharani U. Letter to the Editor: "Approach to the Patient with Thyrotoxicosis Using Telemedicine". J Clin Endocrinol Metab 2021; 106:e1060-e1061. [PMID: 33038240 DOI: 10.1210/clinem/dgaa723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Aaron B Neinstein
- Department of Medicine, University of California, San Francisco, San Francisco, California
- UCSF Center for Digital Health Innovation, San Francisco, California
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, San Francisco, California
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25
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Kim S, Conrad M, Chuang E, Cai L, Masharani U, Murphy EJ. Calcium Stimulation Test for Insulinoma Localization in an End-stage Renal Disease Patient on Diazoxide. J Endocr Soc 2020; 5:bvaa185. [PMID: 33381673 PMCID: PMC7750930 DOI: 10.1210/jendso/bvaa185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Indexed: 12/04/2022] Open
Abstract
Insulinomas are rare, and even rarer in patients with end-stage renal disease (ESRD). Clear criteria for the biochemical diagnosis of insulinomas in patients with renal failure have not been established, and hypoglycemia is often attributed to the renal disease itself, frequently leading to a delay in diagnosis. We describe a case of a patient who presented with asymptomatic recurrent hypoglycemia during hemodialysis. Disease progression and biochemical testing strongly suggested an insulinoma. Computed tomography (CT) of the abdomen and pelvis, 111In-pentetreotide scintigraphy and endoscopic ultrasound did not localize a pancreatic tumor. A calcium stimulation test was performed while the patient was taking diazoxide due to severe hypoglycemia with fasting for a couple of hours without treatment. The test showed a marked increase in insulin after calcium infusion in the dorsal pancreatic artery, localizing the tumor to the body and tail of the gland. Exploratory surgery easily identified a tumor at the body of the pancreas and pathology confirmed an insulin-secreting pancreatic neuroendocrine tumor. On follow-up, there was resolution of the hypoglycemia. We review the challenges of diagnosing an insulinoma in ESRD and describe a successful intra-arterial calcium stimulation test done in an ESRD patient while continuing diazoxide.
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Affiliation(s)
- Stephanie Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Miles Conrad
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Eunice Chuang
- Division of Endocrinology and Metabolism, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Larry Cai
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Umesh Masharani
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth J Murphy
- Division of Endocrinology and Metabolism, Department of Medicine, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.,Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
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26
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Kou S, De Cunto C, Baujat G, Wentworth KL, Grogan DR, Brown MA, Di Rocco M, Keen R, Al Mukaddam M, le Quan Sang KH, Masharani U, Kaplan FS, Pignolo RJ, Hsiao EC. Patients with ACVR1 R206H mutations have an increased prevalence of cardiac conduction abnormalities on electrocardiogram in a natural history study of Fibrodysplasia Ossificans Progressiva. Orphanet J Rare Dis 2020; 15:193. [PMID: 32727600 PMCID: PMC7389682 DOI: 10.1186/s13023-020-01465-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/08/2020] [Indexed: 01/02/2023] Open
Abstract
Background Genetic contributors to cardiac arrhythmias are often found in cardiovascular conduction pathways and ion channel proteins. Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare disease of massive heterotopic ossification caused by a highly recurrent R206H mutation in ACVR1/ALK2. This mutation causes abnormal activation of the bone morphogenetic protein (BMP) pathway in response to Activin A. Prior studies suggested increased risks of cardiopulmonary complications in FOP. We examined participants in a Natural History Study (NHS) of FOP (ClinicalTrials.gov #NCT02322255) to better understand their cardiovascular status. Methods The NHS is an ongoing 3 year international multi-center longitudinal study of 114 patients (ages 4–56 years) with genetically confirmed ACVR1/ALK2R206H FOP. Patients were clinically assessed at baseline and 12 months. Electrocardiograms (ECGs) were reviewed in a central ECG laboratory. Conduction abnormalities were compared against clinical data collected in the NHS, and echocardiograms collected from NHS and non-NHS patients. Results Conduction abnormalities were present in 45.3% of baseline ECGs, with the majority of abnormalities classified as nonspecific intraventricular conduction delay (37.7%). More specifically, 22.2% of patients > 18 years old had conduction abnormalities, which was significantly higher than a prior published study of a healthy population (5.9%; n = 3978) (p < 0.00001). Patients with FOP < 18 years old also had a high prevalence of conduction abnormalities (62.3%). The 12-month follow up data was similar to baseline results. Conduction abnormalities did not correlate with chest wall deformities, scoliosis, pulmonary function test results, or increased Cumulative Analog Joint Involvement Scale scores. Echocardiograms from 22 patients with FOP revealed 8 with structural cardiac abnormalities, only 1 of which correlated with a conduction abnormality. Conclusions We found that patients with FOP may have subclinical conduction abnormalities manifesting on ECG, independent of heterotopic ossification. Although clinically significant heart disease is not typically associated with FOP, and the clinical implications for cardiovascular risk remain unclear, knowledge about ECG and echocardiogram changes is important for clinical care and research trials in patients with FOP. Further studies on how ACVR1/ALK2R206H affects cardiac health will help elucidate the underlying mechanism.
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Affiliation(s)
- Samuel Kou
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Carmen De Cunto
- Pediatric Rheumatology Section, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Geneviève Baujat
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Kelly L Wentworth
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA.,Division of Endocrinology and Metabolism, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Donna R Grogan
- Clementia Pharmaceuticals, an Ipsen Company, Montreal, Canada
| | - Matthew A Brown
- Guy's & St. Thomas' NHS Foundation Trust and King's College London NIHR Biomedical Research Centre, London, England
| | - Maja Di Rocco
- Unit of Rare Diseases, Department of Pediatrics, Giannina Gaslini Institute, Genoa, Italy
| | - Richard Keen
- Centre for Metabolic Bone Disease, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Mona Al Mukaddam
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kim-Hanh le Quan Sang
- Department de Genetique Institut IMAGINE and Hôpital Necker-Enfants Malades, Paris, France
| | - Umesh Masharani
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA
| | - Frederick S Kaplan
- Department of Medicine, Perelman School Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Orthopaedic Surgery and The Center of Research for FOP & Related Disorders, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Edward C Hsiao
- Division of Endocrinology and Metabolism, the UCSF Metabolic Bone Clinic, University of California- San Francisco, 513 Parnassus Ave., HSE901G, San Francisco, CA, 94143-0794, USA. .,The Institute for Human Genetics and the Program in Craniofacial Biology, University of California, San Francisco, CA, USA.
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27
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Quandt Z, Kim S, Villanueva-Meyer J, Coupe C, Tyrrell JB, Bluestone JA, Anderson MS, Masharani U. SUN-298 Spectrum of Imaging in Immune Checkpoint Inhibitor Induced Hypophysitis. J Endocr Soc 2020. [PMCID: PMC7207307 DOI: 10.1210/jendso/bvaa046.1584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Hypophysitis (HP) is a known immune related adverse event of immune checkpoint inhibitors (CPIs), commonly associated with CTLA-4 inhibitors and rarely with PD-1/PD-L1 inhibitors. Prior studies of MRIs at HP diagnosis noted pituitary enlargement with resolution within a few weeks. In this study, we examine MRI changes in patients with CPI-induced HP. Methods: Subjects with biochemical evidence of central hypothyroidism or central adrenal insufficiency and MRIs were reviewed by endocrinology and neuroradiology. MRIs were classified relative to HP diagnosis: baseline (at least 21 days prior), diagnosis (within 21 days), and follow up (over 21 days). Patient characteristics included age at CPI initiation, sex, race/ethnicity, personal and family history of autoimmunity, type of cancer and CPI. Results: Twenty-six subjects met the inclusion criteria. The mean age was 59 years; 62% were male and 86% were non-Hispanic white. Nineteen percent had a personal history and 31% a family history of autoimmunity. Fifty percent had melanoma. At HP diagnosis, 46% were on PD-1/PD-L1 inhibitors, 42% were on combination PD-1/CTLA-4 inhibitors and 12% were on CTLA-4 inhibitors. Median time from CPI initiation to HP diagnosis was 95 days. Time to HP was shorter on a CTLA-4 inhibitor combination or monotherapy (median 82 days) compared to a PD-1/PD-L1 inhibitor monotherapy (median 220 days; Wilcoxon rank sum, p <0.01). Central adrenal insufficiency was present in all patients not yet on steroids. Central hypothyroidism was common (10/19) in those without primary thyroid disease and was not associated with type of CPI (Fisher’s exact, p=0.18). Thirteen subjects had baseline MRIs, 18 had MRIs at HP diagnosis and 13 had MRIs in the follow up period. Baseline MRIs were normal in 12/13; one subject had an enlarged pituitary. At diagnosis, 10 had an enlarged pituitary, 7 a normal pituitary and 1 a partially empty sella. CTLA-4 inhibitor exposure was associated with pituitary enlargement at diagnosis: 9/11 compared to 1/7 on PD-1/PD-L1 inhibitor (Fisher’s exact, p <0.04). Of the subjects who had follow-up MRIs, 3 had an enlarged pituitary, 7 a normal pituitary and 3 a partially empty sella. Follow up imaging did not differ between treatment types (Fisher’s exact, p >0.05). Timing of MRI was significantly associated with pituitary appearance (Fisher’s exact, p <0.01). Conclusion: The MRI appearance of HP presents as a spectrum, from a partially empty sella, normal pituitary to an enlarged pituitary. HP diagnosed in the setting of CTLA-4 inhibitor treatment occurs earlier and is more likely to induce an enlarged pituitary gland compared to PD-1/PD-L1 monotherapy, which occurs later and is associated with a normal appearing MRI at diagnosis. This suggests that the pathogenesis of HP following CPI exposure may vary depending on the type of CPI.
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Affiliation(s)
| | - Stephanie Kim
- University of California, San Francisco, San Francisco, CA, USA
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Hessler D, Fisher L, Polonsky W, Strycker L, Parra J, Bowyer V, Dedhia M, Masharani U. There is value in treating elevated levels of diabetes distress: the clinical impact of targeted interventions in adults with Type 1 diabetes. Diabet Med 2020; 37:71-74. [PMID: 31314907 DOI: 10.1111/dme.14082] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2019] [Indexed: 11/28/2022]
Abstract
AIM To compare the effect of targeted interventions to reduce high diabetes distress among adults with Type 1 diabetes with a comparison sample of similar but untreated individuals, and to document the stability of untreated diabetes distress over time. METHODS A total of 51 adults with Type 1 diabetes with elevated baseline diabetes distress (distress score ≥ 2.0) and HbA1c levels (≥ 58 mmol/mol) were identified from a longitudinal, non-intervention study, and compared with a similar sample of 51 participants in an intervention study. Both groups completed the T1-DDS diabetes distress questionnaire at baseline and 9 months. RESULTS Large and significant reductions in diabetes distress scores were recorded in the intervention group (mean ± sd change = -0.6 ± 0.6), while minimal change was found in the non-intervention group (-0.2 ± 0.6, group effect P = 0.002; effect size d = 0.67). Additional analyses using the established minimal clinically important difference for the T1-DDS showed that diabetes distress increased significantly (minimal clinically important difference ≥ 1) or persisted at high levels for 51% of participants in the non-intervention group, compared with 23.5% in the intervention group. CONCLUSION Our results showed that targeted interventions led to dramatic reductions in diabetes distress compared with a lack of treatment. We also conclude that elevated diabetes distress, when left unaddressed, does not resolve over time and often remains chronic. (Clinical Trials Registry no.: NCT02175732).
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Affiliation(s)
- D Hessler
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - L Fisher
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - W Polonsky
- Behavioural Diabetes Institute, Department of Psychiatry, University of California, San Diego, CA, USA
| | - L Strycker
- Oregon Research Institute, Eugene, OR, USA
| | - J Parra
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - V Bowyer
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M Dedhia
- Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - U Masharani
- Department of Medicine, University of California, San Francisco, CA, USA
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Shumway M, Fisher L, Hessler D, Bowyer V, Polonsky WH, Masharani U. Economic costs of implementing group interventions to reduce diabetes distress in adults with type 1 diabetes mellitus in the T1-REDEEM trial. J Diabetes Complications 2019; 33:107416. [PMID: 31473079 PMCID: PMC6823162 DOI: 10.1016/j.jdiacomp.2019.107416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/08/2019] [Accepted: 08/10/2019] [Indexed: 10/26/2022]
Abstract
AIMS This study evaluated the implementation costs of two group interventions, one focused on diabetes education (KnowIt) and one focused directly on diabetes distress (OnTrack), that reduced diabetes distress and HbA1C in adults with poorly controlled type 1 diabetes (T1DM) in the T1-REDEEM trial. METHODS Resources used to provide interventions were enumerated using activity-based micro-costing methods. Costs were assigned to resources in 2017 US dollars. US median wage and benefit rates were used to calculate costs of staff time. Cost per unit change was calculated for diabetes distress and HbA1C. RESULTS For both interventions, per participant implementation costs were approximately $250 and cost per 1.0 percentage point (11 mmol/mol) change in HbA1C was $1400. Cost per unit change in diabetes distress was $364 for KnowIt and $335 for OnTrack. No statistically significant differences in costs were observed. CONCLUSIONS This is the first study to examine the costs of implementing interventions targeting diabetes distress in the context of T1DM. Both interventions had per participant implementation costs in the lower end of the range of previously examined diabetes self-management interventions ($219 to $5390). These inventions and their costs merit further attention because reducing diabetes distress may impact long term T1DM outcomes. CLINICAL TRIALS REGISTRATION ClinicalTrials.govNCT02175732.
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MESH Headings
- Adult
- Anxiety/economics
- Anxiety/etiology
- Anxiety/therapy
- Cost-Benefit Analysis
- Depression/economics
- Depression/etiology
- Depression/therapy
- Diabetes Mellitus, Type 1/economics
- Diabetes Mellitus, Type 1/epidemiology
- Diabetes Mellitus, Type 1/psychology
- Diabetes Mellitus, Type 1/therapy
- Group Processes
- Health Care Costs
- Humans
- Implementation Science
- Middle Aged
- Patient Acceptance of Health Care/statistics & numerical data
- Patient Education as Topic/economics
- Patient Education as Topic/methods
- Psychological Distress
- Psychotherapy, Group/economics
- Psychotherapy, Group/methods
- Self Care/economics
- Self Care/methods
- Stress, Psychological/economics
- Stress, Psychological/epidemiology
- Stress, Psychological/etiology
- Stress, Psychological/therapy
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Affiliation(s)
- Martha Shumway
- Department of Psychiatry, University of California, San Francisco, Box 0884, San Francisco, CA 94143-0884, USA.
| | - Lawrence Fisher
- Department of Family and Community Medicine, University of California, San Francisco, Box 0900, San Francisco, CA 94143-0900, USA
| | - Danielle Hessler
- Department of Family and Community Medicine, University of California, San Francisco, Box 0900, San Francisco, CA 94143-0900, USA
| | - Vicky Bowyer
- Department of Family and Community Medicine, University of California, San Francisco, Box 0900, San Francisco, CA 94143-0900, USA
| | - William H Polonsky
- Behavioral Diabetes Institute, 5405 Oberlin Drive #100, San Diego, CA 92121, USA
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, Box 1222, San Francisco, CA 94143-1222, USA
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Masharani U, Alba D. Methadone-Associated Hypoglycemia in Chronic Renal Failure Masquerading as an Insulinoma. Pain Med 2019; 19:1876-1878. [PMID: 29145621 DOI: 10.1093/pm/pnx280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Umesh Masharani
- Department of Medicine, University of California, San Francisco, San Francisco, California 94143, USA
| | - Diana Alba
- Department of Medicine, University of California, San Francisco, San Francisco, California 94143, USA
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Fisher L, Hessler D, Polonsky W, Strycker L, Bowyer V, Masharani U. Toward effective interventions to reduce diabetes distress among adults with type 1 diabetes: Enhancing Emotion regulation and cognitive skills. Patient Educ Couns 2019; 102:1499-1505. [PMID: 30952482 PMCID: PMC6565487 DOI: 10.1016/j.pec.2019.03.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE We tested three models to determine how improvements in emotion regulation (ER) and cognitive skills (CS) as a result of intervention operate to affect reductions in diabetes distress DD. METHODS Change data were drawn from the baseline and 9-month T1-REDEEM trial. Adults with type 1 diabetes were recruited from several U.S. states and Toronto, Canada. A primary and two alternative structural equation models were tested to explore the directionality of effect: primary model - changes in ER and CS drive changes in DD; reverse model - changes in DD drive changes in ER and CS; and bidirectional model - changes in ER, CS and DD occur together with no directionality. RESULTS All three models displayed a good fit to the data. The primary model indicated 7 significant directional pathways: improvements in ER and CS operate together to drive reductions in DD. The reverse model only indicated that reductions in DD affected changes in one CS variable; and the bidirectional model indicated only that these results were bidirectional. Reductions in all tested domains of DD occurred together. CONCLUSIONS Improvements in ER and CS drive reductions in DD. PRACTICE IMPLICATIONS Interventions to reduce high DD should focus on improving ER and CS.
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Affiliation(s)
- Lawrence Fisher
- Department of Family & Community Medicine, University of California, San Francisco, CA, USA.
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California, San Francisco, CA, USA.
| | - William Polonsky
- Behavioral Diabetes Institute, Department of Psychiatry, University of California, San Diego, CA, USA.
| | | | - Vicky Bowyer
- Department of Family & Community Medicine, University of California, San Francisco, CA, USA.
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, CA, USA.
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Kim S, Dillon W, Hope T, El-Sayed I, van Zante A, Masharani U. SAT-618 Ectopic Thyroid-Stimulating Hormone-Secreting Pituitary Adenoma of the Nasopharynx Diagnosed by 68Ga-DOTA-TATE PET/CT. J Endocr Soc 2019. [PMCID: PMC6551902 DOI: 10.1210/js.2019-sat-618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare, accounting for up to 3% of all pituitary tumors. Ectopic TSH-secreting tumors are even rarer and can be difficult to detect. We report the first use of 68Gallium (Ga)-DOTA-TATE PET/CT to diagnose an ectopic TSH-secreting tumor located in the nasopharynx. Clinical case A 48-year-old woman presented to clinic for evaluation of hyperthyroidism. Three years prior to presentation, the patient complained of typical hyperthyroid symptoms. Thyroid function tests showed TSH 3.57 uIU/ml (ref 0.34-4.82); fT4 2.37 ng/dL (0.76-1.8); TT4 24 ug/dL (4.7-13.3); fT3 5.18 pg/mL (2.3-4.2); TT3 260 ng/dL (87-167). Over the next three years, she had persistently elevated T4 and T3 with normal TSH, despite treatment with thionamides. A RAIU scan showed diffuse thyroid gland uptake without any evidence of a focal hyper- or hypofunctioning nodule and a thyroid ultrasound revealed heterogeneous echogenicity and a 1.9 x 0.8 x 1.3 cm hypoechoic solid nodule within the isthmus. On her initial evaluation, physical examination was notable for an enlarged thyroid gland and resting tremor in bilateral hands. Thyroid function tests remained similar to prior; Tg antibodies <2 IU/mL (ref <2); TPO antibody <63 (<101); TSI <89% (<140); TBII <1% (<16). Dilution and heterophile antibody blocking studies were negative and TSH measured on different laboratory assays yielded similar results. Alpha subunit was 0.3 with alpha subunit to TSH ratio 1.16. On review of her prior images, she was noted to have a mildly enhancing 9 x 10 mm nodule in the nasopharynx extending from the posterior aspect of the nasal septum and a normal pituitary. 68Ga-DOTA-TATE PET/CT revealed a 6 x 8 x 11 mm nasopharyngeal soft tissue nodule attached to the right posterior nasal septum, compatible with a neuroendocrine tumor. The patient underwent successful endoscopic resection of the mass. Intraoperatively, a pedunculated tumor arising from posterior nasal septum and anterior sphenoid wall on the right was noted. Pathology confirmed ectopic pituitary neoplasm with immunohistochemical staining positive for PRL and TSH, and negative for ACTH. Immediately postoperatively, she had a high fT4 and low TSH. Even after her fT4 normalized, her TSH remained partially suppressed at 2 months, but fully recovered at 5 months. Conclusion Ectopic TSH-secreting pituitary adenomas are rare. We describe the tenth case of an ectopic TSH-secreting pituitary adenoma located in the nasopharynx in a patient who presented with signs and symptoms of hyperthyroidism. Our case was the first, to our knowledge, to utilize the somatostatin receptor agent 68Ga-DOTA-TATE to aid in identifying the lesion, emphasizing the importance of recognizing 68Ga-DOTA-TATE PET/CT as an imaging modality in the diagnosis of ectopic pituitary adenomas, as these tumors can be challenging to diagnose radiographically.
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Affiliation(s)
- Stephanie Kim
- University of California, San Francisco, San Francisco, CA, United States
| | - William Dillon
- University of California, San Francisco, San Francisco, CA, United States
| | - Thomas Hope
- University of California, San Francisco, San Francisco, CA, United States
| | - Ivan El-Sayed
- University of California, San Francisco, San Francisco, CA, United States
| | | | - Umesh Masharani
- DEPT OF MED, University of California, San Francisco, San Francisco, CA, United States
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Ferket B, Hunink MM, Masharani U, Max W, Fleischmann K. LIFETIME INCIDENCE OF CORONARY ARTERY CALCIUM FOR ASYMPTOMATIC INDIVIDUALS WITH AND WITHOUT DIABETES: INSIGHTS FROM THE MULTI-ETHNIC STUDY OF ATHEROSCLEROSIS. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)32374-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kim S, Dillon WP, Hope TA, El-Sayed IH, van Zante A, Wu K, Masharani U. Ectopic Thyroid-Stimulating Hormone-Secreting Pituitary Adenoma of the Nasopharynx Diagnosed by Gallium 68 DOTATATE Positron Emission Tomography/Computed Tomography. World Neurosurg 2019; 125:400-404. [PMID: 30797906 DOI: 10.1016/j.wneu.2019.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/10/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ectopic thyroid-secreting hormone (TSH)-secreting pituitary adenomas are rare, with only 9 cases reported in the literature. CASE DESCRIPTION We describe a case of an ectopic TSH-secreting pituitary adenoma located in the nasopharynx in a patient initially presenting with signs and symptoms of hyperthyroidism that persisted despite treatment with antithyroid medications. Magnetic resonance imaging of the pituitary gland was normal, although subsequent review by a neuroradiologist revealed a nodule attached to the posterior septum in the nasopharynx that was, in retrospect, seen on several other magnetic resonance imaging scans. Gallium 68 (68Ga) DOTATATE positron emission tomography/computed tomography showed increased uptake in the nasopharyngeal nodule. The patient underwent resection of the nasopharyngeal mass with remission of hyperthyroidism. On pathology, the resected mass stained positive for TSH and prolactin. CONCLUSIONS This is the first report of use of 68Ga-DOTATATE positron emission tomography/computed tomography to aid in localizing an ectopic TSH-secreting tumor. Prior studies have shown that 68Ga-DOTATATE positron emission tomography/computed tomography improves detection of small lesions with shorter imaging times and lower radiation doses compared with other modalities. Our case emphasizes the importance of using 68Ga-DOTATATE PET/CT in the diagnosis of ectopic pituitary adenomas, as these tumors can be challenging to diagnose radiographically.
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Affiliation(s)
- Stephanie Kim
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
| | - William P Dillon
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Division of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Annemieke van Zante
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
| | - Karin Wu
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Umesh Masharani
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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Wentworth KL, Masharani U, Hsiao EC. Therapeutic advances for blocking heterotopic ossification in fibrodysplasia ossificans progressiva. Br J Clin Pharmacol 2019; 85:1180-1187. [PMID: 30501012 DOI: 10.1111/bcp.13823] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/30/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare genetic disease in which heterotopic bone forms in muscle and soft tissue, leading to joint dysfunction and significant disability. FOP is progressive and many patients are wheelchair-bound by the 3rd decade of life. FOP is caused by an activating mutation in the ACVR1 gene, which encodes the activin A Type 1 receptor. Aberrant signalling through this receptor leads to abnormal activation of the pSMAD 1/5/8 pathway and triggers the formation of bone outside of the skeleton. There is no curative therapy for FOP; however, exciting advances in novel therapies have developed recently. Here, we review the clinical and translational pharmacology of three drugs that are currently in clinical trials (palovarotene, REGN 2477 and rapamycin) as well as other emerging treatment strategies for FOP.
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Affiliation(s)
- Kelly L Wentworth
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Umesh Masharani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, CA, USA.,Institute for Human Genetics, University of California, San Francisco, CA, USA
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Fisher L, Hessler D, Polonsky WH, Masharani U, Guzman S, Bowyer V, Strycker L, Ahmann A, Basina M, Blumer I, Chloe C, Kim S, Peters AL, Shumway M, Weihs K, Wu P. T1-REDEEM: A Randomized Controlled Trial to Reduce Diabetes Distress Among Adults With Type 1 Diabetes. Diabetes Care 2018; 41:1862-1869. [PMID: 29976567 PMCID: PMC6105321 DOI: 10.2337/dc18-0391] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 06/09/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the effectiveness of two interventions to reduce diabetes distress (DD) and improve glycemic control among adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS Individuals with T1D (n = 301) with elevated DD and HbA1c were recruited from multiple settings and randomly assigned to OnTrack, an emotion-focused intervention, or to KnowIt, an educational/behavioral intervention. Each group attended a full-day workshop plus four online meetings over 3 months. Assessments occurred at baseline and 3 and 9 months. Primary and secondary outcomes were change in DD and change in HbA1c, respectively. RESULTS With 12% attrition, both groups demonstrated dramatic reductions in DD (effect size d = 1.06; 78.4% demonstrated a reduction of at least one minimal clinically important difference). There were, however, no significant differences in DD reduction between OnTrack and KnowIt. Moderator analyses indicated that OnTrack provided greater DD reduction to those with initially poorer cognitive or emotion regulation skills, higher baseline DD, or greater initial diabetes knowledge than those in KnowIt. Significant but modest reductions in HbA1c occurred with no between-group differences. Change in DD was modestly associated with change in HbA1c (r = 0.14, P = 0.01), with no significant between-group differences. CONCLUSIONS DD can be successfully reduced among distressed individuals with T1D with elevated HbA1c using both education/behavioral and emotion-focused approaches. Reductions in DD are only modestly associated with reductions in HbA1c. These findings point to the importance of tailoring interventions to address affective, knowledge, and cognitive skills when intervening to reduce DD and improve glycemic control.
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Affiliation(s)
| | | | | | | | | | - Vicky Bowyer
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Charles Chloe
- Veterans Affairs San Diego Healthcare System, University of California, San Diego, San Diego, CA
| | - Sarah Kim
- University of California, San Francisco, San Francisco, CA
| | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Martha Shumway
- University of California, San Francisco, San Francisco, CA
| | - Karen Weihs
- University of Arizona College of Medicine, Tucson, AZ
| | - Patricia Wu
- Kaiser Permanente Medical Group, San Diego, CA
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Fisher L, Hessler D, Polonsky W, Strycker L, Guzman S, Bowyer V, Blumer I, Masharani U. Emotion regulation contributes to the development of diabetes distress among adults with type 1 diabetes. Patient Educ Couns 2018; 101:124-131. [PMID: 28739179 PMCID: PMC5732076 DOI: 10.1016/j.pec.2017.06.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/15/2017] [Accepted: 06/26/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To demonstrate how maladaptive emotion regulation (ER) can lead to diabetes distress (DD), with subsequent effects on management and metabolic outcomes among adults with type 1 diabetes. METHODS Data are based on pre-intervention assessment for a random controlled trial to reduce DD. Patients were recruited in California, Oregon, Arizona and Ontario, Canada. After screening and consent, patients completed an online assessment and released their most recent laboratory HbA1C. Structural equation modeling was used to define an ER measurement model and test for significant pathways. RESULTS Three ER mechanisms combined into a single construct: emotion processing, non-judgment of emotions, non-reactivity to emotions. Models indicated a significant pathway from ER and cognitions to DD to disease management to metabolic control. CONCLUSIONS As hypothesized, the three ER mechanisms formed a single, coherent ER construct. Patients with poor ER reported high DD; and high DD was linked to poor diabetes management and poor metabolic control. PRACTICE IMPLICATIONS Identifying both the level of DD and the ER mechanisms that lead to high DD should be explored in clinical settings. Helping T1Ds to become more aware, less judgmental and less reactive behaviorally to what they feel about diabetes and its management may reduce DD.
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Affiliation(s)
- Lawrence Fisher
- Department of Family & Community Medicine, UCSF, San Francisco, CA, USA.
| | - Danielle Hessler
- Department of Family & Community Medicine, UCSF, San Francisco, CA, USA.
| | - William Polonsky
- Behavioral Diabetes Institute, Department of Psychiatry, UCSD, San Diego, CA, USA.
| | | | - Susan Guzman
- Behavioral Diabetes Institute, San Diego, CA, USA.
| | - Vicky Bowyer
- Department of Family & Community Medicine, UCSF, San Francisco, CA, USA.
| | - Ian Blumer
- Charles H. Best Diabetes Centre, Ontario, Canada.
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Hessler DM, Fisher L, Polonsky WH, Masharani U, Strycker LA, Peters AL, Blumer I, Bowyer V. Diabetes distress is linked with worsening diabetes management over time in adults with Type 1 diabetes. Diabet Med 2017; 34:1228-1234. [PMID: 28498610 PMCID: PMC5561505 DOI: 10.1111/dme.13381] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2017] [Indexed: 12/20/2022]
Abstract
AIM To determine the cross-sectional and longitudinal associations between diabetes distress and diabetes management. METHODS In a non-interventional study, 224 adults with Type 1 diabetes were assessed for diabetes distress, missed insulin boluses, hypoglycaemic episodes, and HbA1c at baseline and 9 months. RESULTS At baseline, greater distress was associated with higher HbA1c and a greater percentage of missed insulin boluses. Longitudinally, elevated baseline distress was related to increased missed insulin boluses, and decreases in distress were associated with decreases in HbA1c . In supplementary analyses, neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA1c or hypoglycaemic episodes in cross-sectional or longitudinal analyses. CONCLUSIONS Significant cross-sectional and longitudinal associations were found between diabetes distress and management; in contrast, no parallel associations were found for major depressive disorder or depression symptoms. Findings suggest that elevated distress may lead to more missed insulin boluses over time, suggesting a potential intervention target. The covarying association between distress and HbA1c points to the complex and likely interactive associations between these constructs. Findings highlight the need to address distress as an integral part of diabetes management in routine care.
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Affiliation(s)
- D M Hessler
- Department of Family & Community Medicine, San Francisco, USA
| | - L Fisher
- Department of Family & Community Medicine, San Francisco, USA
| | - W H Polonsky
- Behavioral Diabetes Institute, San Francisco, USA
| | - U Masharani
- Department of Medicine, University of California-San Francisco, San Francisco, USA
| | | | - A L Peters
- University of Southern California, Los Angeles, USA
| | - I Blumer
- Charles H. Best Diabetes Centre, Ontario, Canada
| | - V Bowyer
- Department of Family & Community Medicine, San Francisco, USA
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Fisher L, Hessler DM, Polonsky WH, Masharani U, Peters AL, Blumer I, Strycker LA. Prevalence of depression in Type 1 diabetes and the problem of over-diagnosis. Diabet Med 2016; 33:1590-1597. [PMID: 26433004 DOI: 10.1111/dme.12973] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2015] [Indexed: 12/19/2022]
Abstract
AIMS To determine the prevalence of depression and diabetes distress in adults with Type 1 diabetes and the rate of false-positives when compared with rates of major depressive disorder. METHODS The sample consisted of 368 individuals with Type 1 diabetes, aged > 19 years. Individuals completed: the eight-item Patient Health Questionnaire depression scale (PHQ8), which was coded using four scoring criteria (scores > 10, >12 and >15, and Diagnostic and Statistical Manual of Mental Disorders 5 (DSM) algorithm scores); the Type 1 Diabetes Distress Scale; and the Structured Clinical Interview for DSM Disorders (SCID) to assess major depressive disorder. RESULTS The prevalence rates of depression according to the eight-item Patient Health Questionnaire were: score >10, 11.4%; score >12, 7.1%; score >15, 3.8%; and positive algorithm result, 4.6%. The prevalence of major depressive disorder was 3.5%; and the prevalence of at least moderate diabetes distress was 42.1%. Depending on the criterion used, the false-positive rate when using the Patient Health Questionnaire compared with the results when using the SCID varied from 52 to 71%. Of those classified as depressed on the PHQ-8 or Structured Clinical Interview for DSM Disorders, between 92.3 and 96.2% also reported elevated diabetes distress. No significant association was found between any group classed as having depression according to the PHQ8 or the SCID and HbA1c concentration. Depression was significantly associated with more other life stress, more complications and a lower level of education. CONCLUSIONS We found an unexpectedly low rate of current depression and major depressive disorder in this diverse sample of adults with Type 1 diabetes, and a very high rate of false-positive results using the Patient Health Questionnaire. Considering the high prevalence of diabetes distress, much of what has been considered depression in adults with Type 1 diabetes may be attributed to the emotional distress associated with managing a demanding chronic disease and other life stressors and not necessarily to underlying psychopathology.
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Affiliation(s)
- L Fisher
- Department of Family and Community Medicine, UCSF, San Francisco, USA.
| | - D M Hessler
- Department of Family and Community Medicine, UCSF, San Francisco, USA
| | | | - U Masharani
- Department of Medicine, UCSF, San Francisco, USA
| | - A L Peters
- University of Southern California, Los Angeles, CA, USA
| | - I Blumer
- Charles H. Best Diabetes Centre, Ontario, Canada
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Fisher L, Hessler D, Polonsky W, Strycker L, Masharani U, Peters A. Diabetes distress in adults with type 1 diabetes: Prevalence, incidence and change over time. J Diabetes Complications 2016; 30:1123-8. [PMID: 27118163 PMCID: PMC4949147 DOI: 10.1016/j.jdiacomp.2016.03.032] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/23/2016] [Accepted: 03/24/2016] [Indexed: 11/22/2022]
Abstract
AIMS To document the prevalence and 9-month incidence of elevated diabetes distress (DD) and the stability of DD over time using both single threshold and minimal clinically important differences (MCID) approaches. METHODS Adults with type 1 diabetes (T1D) (N=224) completed the 28-item T1-Diabetes Distress Scale (T1-DDS) at baseline and 9months. A T1-DDS threshold was identified with spline analysis and MCID was calculated from the standard error of measurement. RESULTS Analyses supported a cut-point of ≥2.0 for elevated DD. The prevalence and 9-month incidence of elevated DD was 42.1% and 54.4%, respectively. MCID was ±0.19 but varied by subscale (.26 to .50). Elevated DD was stable: only 20% crossed 2.0 over 9months. MCID analyses showed that change also occurred among those who remained either below or above 2.0 over time. Change varied by source of distress, with Powerlessness the most prevalent and stable. Using MCID, only participant age, gender and number of complications predicted change. CONCLUSIONS The prevalence, 9-month incidence and stability of elevated DD are high among adults with T1D, with change based on source of DD. We propose a combined cut-point/MCID framework for measuring change in DD, since each approach reflects unique characteristics of change over time.
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Affiliation(s)
- Lawrence Fisher
- Department of Family & Community Medicine, University of California,s San Francisco, San Francisco, CA, USA.
| | - Danielle Hessler
- Department of Family & Community Medicine, University of California,s San Francisco, San Francisco, CA, USA
| | - William Polonsky
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA; Behavioral Diabetes Institute, San Diego, CA, USA
| | | | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Anne Peters
- University of Southern California, Los Angeles, CA, USA
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Bailey K, Yazdi T, Masharani U, Tyrrell B, Butch A, Schaufele F. Advantages and Limitations of Androgen Receptor-Based Methods for Detecting Anabolic Androgenic Steroid Abuse as Performance Enhancing Drugs. PLoS One 2016; 11:e0151860. [PMID: 26998755 PMCID: PMC4801337 DOI: 10.1371/journal.pone.0151860] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 03/04/2016] [Indexed: 12/19/2022] Open
Abstract
Testosterone (T) and related androgens are performance enhancing drugs (PEDs) abused by some athletes to gain competitive advantage. To monitor unauthorized androgen abuse, doping control programs use mass spectrometry (MS) to detect androgens, synthetic anabolic-androgenic steroids (AASs) and their metabolites in an athlete’s urine. AASs of unknown composition will not be detected by these procedures. Since AASs achieve their anabolic effects by activating the Androgen Receptor (AR), cell-based bioassays that measure the effect of a urine sample on AR activity are under investigation as complementary, pan-androgen detection methods. We evaluated an AR BioAssay as a monitor for androgen activity in urine pre-treated with glucuronidase, which releases T from the inactive T-glucuronide that predominates in urine. AR BioAssay activity levels were expressed as ‘T-equivalent’ concentrations by comparison to a T dose response curve. The T-equivalent concentrations of androgens in the urine of hypogonadal participants supplemented with T (in whom all androgenic activity should arise from T) were quantitatively identical to the T measurements conducted by MS at the UCLA Olympic Analytical Laboratory (0.96 ± 0.22). All 17 AASs studied were active in the AR BioAssay; other steroids were inactive. 12 metabolites of 10 commonly abused AASs, which are used for MS monitoring of AAS doping because of their prolonged presence in urine, had reduced or no AR BioAssay activity. Thus, the AR BioAssay can accurately and inexpensively monitor T, but its ability to monitor urinary AASs will be limited to a period immediately following doping in which the active AASs remain intact.
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Affiliation(s)
- Kathy Bailey
- Center for Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Tahmineh Yazdi
- Center for Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Umesh Masharani
- Division of Endocrinology, University of California San Francisco, San Francisco, California, United States of America
| | - Blake Tyrrell
- Division of Endocrinology, University of California San Francisco, San Francisco, California, United States of America
| | - Anthony Butch
- Department of Pathology and Laboratory Medicine, Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Fred Schaufele
- Center for Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America.,Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, California, United States of America
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Moassesfar S, Masharani U, Frassetto LA, Szot GL, Tavakol M, Stock PG, Posselt AM. A Comparative Analysis of the Safety, Efficacy, and Cost of Islet Versus Pancreas Transplantation in Nonuremic Patients With Type 1 Diabetes. Am J Transplant 2016; 16:518-26. [PMID: 26595767 PMCID: PMC5549848 DOI: 10.1111/ajt.13536] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/28/2015] [Accepted: 08/15/2015] [Indexed: 01/25/2023]
Abstract
Few current studies compare the outcomes of islet transplantation alone (ITA) and pancreas transplantation alone (PTA) for type 1 diabetes (T1D). We examined these two beta cell replacement therapies in nonuremic patients with T1D with respect to safety, graft function and cost. Sequential patients received PTA (n = 15) or ITA (n = 10) at our institution. Assessments of graft function included duration of insulin independence; glycemic control, as measured by hemoglobin A1c; and elimination of severe hypoglycemia. Cost analysis included all normalized costs associated with transplantation and inpatient management. ITA patients received one (n = 6) or two (n = 4) islet transplants. Mean duration of insulin independence in this group was 35 mo; 90% were independent at 1 year, and 70% were independent at 3 years. Mean duration of insulin independence in PTA was 55 mo; 93% were insulin independent at 1 year, and 64% were independent at 3 years. Glycemic control was comparable in all patients with functioning grafts, as were overall costs ($138 872 for ITA, $134 748 for PTA). We conclude that with advances in islet isolation and posttransplant management, ITA can produce outcomes similar to PTA and represents a clinically viable option to achieve long-term insulin independence in selected patients with T1D.
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Affiliation(s)
- S. Moassesfar
- Pediatrics, University of California, San Francisco, San Francisco, CA
| | - U. Masharani
- Medicine, University of California, San Francisco, San Francisco, CA
| | - L. A. Frassetto
- Medicine, University of California, San Francisco, San Francisco, CA
| | - G. L. Szot
- Transplant Surgery, University of California, San Francisco, San Francisco, CA
| | - M. Tavakol
- Transplant Surgery, University of California, San Francisco, San Francisco, CA
| | - P. G. Stock
- Transplant Surgery, University of California, San Francisco, San Francisco, CA
| | - A. M. Posselt
- Transplant Surgery, University of California, San Francisco, San Francisco, CA,Corresponding author: Andrew M. Posselt,
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Hindi SM, Wang Y, Jones KD, Nussbaum JC, Chang Y, Masharani U, Bikle D, Shoback DM, Hsiao EC. A Case of Hypercalcemia and Overexpression of CYP27B1 in Skeletal Muscle Lesions in a Patient with HIV Infection After Cosmetic Injections with Polymethylmethacrylate (PMMA) for Wasting. Calcif Tissue Int 2015; 97:634-9. [PMID: 26253396 PMCID: PMC4861400 DOI: 10.1007/s00223-015-0048-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 07/29/2015] [Indexed: 10/23/2022]
Abstract
Foreign body-induced granuloma is an uncommon yet clinically significant cause of hypercalcemia. The molecular mechanisms are uncertain, although extrarenal calcitriol production has been proposed. We describe severe hypercalcemia associated with increased levels of plasma calcitriol in a patient with HIV and local granulomatous reaction 5 years after injection of polymethylmethacrylate (PMMA) as dermal filler for cosmetic body sculpting. Extensive evaluation revealed no identifiable cause of increased calcitriol levels. Nuclear imaging was remarkable for diffuse uptake in the subcutaneous tissues of the buttocks. Subsequent muscle biopsy and immunohistochemical staining showed strong local expression of CYP27B1 within histiocytes surrounding globules of PMMA. This case highlights an unfortunate complication of dermal fillers and shows that inflammatory cells can express high levels of CYP27B1 even without frank granulomas. The growing trend of body contour enhancement using injectable fillers should raise suspicion for this cause of hypercalcemia in clinical practice. Patients with HIV who receive this treatment for lipodystrophy or other cosmetic purposes may have increased susceptibility to hypercalcemia in the setting of underlying chronic inflammation. This may be a concern when changing anti-retroviral therapy, since alterations in levels of HIV viremia may initiate or contribute to worsening hypercalcemia.
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Affiliation(s)
- Sahar M Hindi
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 513 Parnassus Ave, HSE901G, UCSF Box 0794, San Francisco, CA, 94143-0794, USA
| | - Yongmei Wang
- Endocrine Research Unit, Department of Veterans Affairs Medical Center, and the Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Kirk D Jones
- Department of Pathology, University of California, San Francisco, San Francisco, CA, USA
| | - Jesse C Nussbaum
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Yongen Chang
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Umesh Masharani
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 513 Parnassus Ave, HSE901G, UCSF Box 0794, San Francisco, CA, 94143-0794, USA
| | - Daniel Bikle
- Endocrine Research Unit, Department of Veterans Affairs Medical Center, and the Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Dolores M Shoback
- Endocrine Research Unit, Department of Veterans Affairs Medical Center, and the Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Edward C Hsiao
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of California, San Francisco, 513 Parnassus Ave, HSE901G, UCSF Box 0794, San Francisco, CA, 94143-0794, USA.
- Institute for Human Genetics, University of California, San Francisco, San Francisco, CA, USA.
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Fisher L, Polonsky WH, Hessler DM, Masharani U, Blumer I, Peters AL, Strycker LA, Bowyer V. Understanding the sources of diabetes distress in adults with type 1 diabetes. J Diabetes Complications 2015; 29:572-7. [PMID: 25765489 PMCID: PMC4414881 DOI: 10.1016/j.jdiacomp.2015.01.012] [Citation(s) in RCA: 226] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 01/26/2015] [Accepted: 01/29/2015] [Indexed: 01/27/2023]
Abstract
AIMS To identify the unique sources of diabetes distress (DD) for adults with type 1 diabetes (T1D). METHODS Sources of DD were developed from qualitative interviews with 25 T1D adults and 10 diabetes health care providers. Survey items were then developed and analyzed using both exploratory (EFA) and confirmatory CFA) analyses on two patient samples. Construct validity was assessed by correlations with depressive symptoms (PHQ8), complications, HbA1C, BMI, and hypoglycemia worry scale (HWS). Scale cut-points were created using multiple regression. RESULTS An EFA with 305 U.S. participants yielded 7 coherent, reliable sources of distress that were replicated by a CFA with 109 Canadian participants: Powerlessness, Negative Social Perceptions, Physician Distress, Friend/Family Distress, Hypoglycemia Distress, Management Distress, Eating Distress. Prevalence of DD was high with 41.6% reporting at least moderate DD. Higher DD was reported for women, those with complications, poor glycemic control, younger age, without a partner, and non-White patients. CONCLUSIONS We identified a profile of seven major sources of DD among T1D using a newly developed assessment instrument. The prevalence of DD is high and is related to glycemic control and several patient demographic and disease-related patient characteristics, arguing for a need to address DD in clinical care.
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Affiliation(s)
- Lawrence Fisher
- Department of Family & Community Medicine, UCSF, San Francisco, California.
| | | | - Danielle M Hessler
- Department of Family & Community Medicine, UCSF, San Francisco, California
| | | | - Ian Blumer
- Charles H. Best Diabetes Centre, Ontario, Canada
| | - Anne L Peters
- University of Southern California, Los Angeles, California
| | | | - Vicky Bowyer
- Department of Family & Community Medicine, UCSF, San Francisco, California
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Kapogiannis D, Boxer A, Schwartz JB, Abner EL, Biragyn A, Masharani U, Frassetto L, Petersen RC, Miller BL, Goetzl EJ. Dysfunctionally phosphorylated type 1 insulin receptor substrate in neural-derived blood exosomes of preclinical Alzheimer's disease. FASEB J 2014; 29:589-96. [PMID: 25342129 DOI: 10.1096/fj.14-262048] [Citation(s) in RCA: 244] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Insulin resistance causes diminished glucose uptake in similar regions of the brain in Alzheimer's disease (AD) and type 2 diabetes mellitus (DM2). Brain tissue studies suggested that insulin resistance is caused by low insulin receptor signaling attributable to its abnormal association with more phospho (P)-serine-type 1 insulin receptor substrate (IRS-1) and less P-tyrosine-IRS-1. Plasma exosomes enriched for neural sources by immunoabsorption were obtained once from 26 patients with AD, 20 patients with DM2, 16 patients with frontotemporal dementia (FTD), and matched case control subjects. At 2 time points, they were obtained from 22 others when cognitively normal and 1 to 10 yr later when diagnosed with AD. Mean exosomal levels of extracted P-serine 312-IRS-1 and P-pan-tyrosine-IRS-1 by ELISA and the ratio of P-serine 312-IRS-1 to P-pan-tyrosine-IRS-1 (insulin resistance factor, R) for AD and DM2 and P-serine 312-IRS-1 and R for FTD were significantly different from those for case control subjects. The levels of R for AD were significantly higher than those for DM2 or FTD. Stepwise discriminant modeling showed correct classification of 100% of patients with AD, 97.5% of patients with DM2, and 84% of patients with FTD. In longitudinal studies of 22 patients with AD, exosomal levels of P-serine 312-IRS-1, P-pan-tyrosine-IRS-1, and R were significantly different 1 to 10 yr before and at the time of diagnosis compared with control subjects. Insulin resistance reflected in R values from this blood test is higher for patients with AD, DM2, and FTD than case control subjects; higher for patients with AD than patients with DM2 or FTD; and accurately predicts development of AD up to 10 yr prior to clinical onset.
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Affiliation(s)
| | - Adam Boxer
- Memory and Aging Center, Department of Neurology, and
| | - Janice B Schwartz
- Jewish Home of San Francisco, San Francisco, California, USA; Department of Medicine, University of California-San Francisco Medical Center, San Francisco, California, USA
| | - Erin L Abner
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, Kentucky, USA; and
| | - Arya Biragyn
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA
| | - Umesh Masharani
- Jewish Home of San Francisco, San Francisco, California, USA
| | - Lynda Frassetto
- Jewish Home of San Francisco, San Francisco, California, USA
| | | | | | - Edward J Goetzl
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland, USA; Jewish Home of San Francisco, San Francisco, California, USA; Department of Medicine, University of California-San Francisco Medical Center, San Francisco, California, USA;
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Fisher L, Hessler D, Masharani U, Strycker L. Impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy. Diabet Med 2014; 31:739-46. [PMID: 24494593 PMCID: PMC4028368 DOI: 10.1111/dme.12403] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 12/13/2013] [Accepted: 01/28/2014] [Indexed: 11/29/2022]
Abstract
AIMS To improve patient-centred care by determining the impact of baseline levels of conscientiousness and diabetes self-efficacy on the outcomes of efficacious interventions to reduce diabetes distress and improve disease management. METHODS Adults with Type 2 diabetes with diabetes distress and self-care problems (N = 392) were randomized to one of three distress reduction interventions: computer-assisted self-management; computer-assisted self-management plus problem-solving therapy; and health education. The baseline assessment included conscientiousness and self-efficacy, demographics, diabetes status, regimen distress, emotional burden, medication adherence, diet and physical activity. Changes in regimen distress, emotional burden and self-care between baseline and 12 months were recorded and ancova models assessed how conscientiousness and self-efficacy qualified the significant improvements in distress and management outcomes. RESULTS Participants with high baseline conscientiousness displayed significantly larger improvements in medication adherence and emotional burden than participants with low baseline conscientiousness. Participants with high baseline self-efficacy showed greater improvements in diet, physical activity and regimen distress than participants with low baseline self-efficacy. The impact of conscientiousness and self-efficacy were independent of each other and occurred across all three intervention groups. A significant interaction indicated that those with both high self-efficacy and high conscientiousness at baseline had the biggest improvement in physical activity by 12 months. CONCLUSIONS Both broad personal traits and disease-specific expectations qualify the outcomes of efficacious interventions. These findings reinforce the need to change from a one-size-fits-all approach to diabetes interventions to an approach that crafts clinical interventions in ways that fit the personal traits and skills of individual people.
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Affiliation(s)
- L Fisher
- Departments of Family and Community Medicine, San Francisco, CA, USA
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Hessler D, Fisher L, Glasgow RE, Strycker LA, Dickinson LM, Arean PA, Masharani U. Reductions in regimen distress are associated with improved management and glycemic control over time. Diabetes Care 2014; 37:617-24. [PMID: 24170750 PMCID: PMC3931383 DOI: 10.2337/dc13-0762] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cross-sectional and longitudinal associations among regimen distress (RD), self-management, and glycemic control were undertaken to explore mechanisms of operation among these variables. RESEARCH DESIGN AND METHODS In a behavioral randomized control trial (RCT) to reduce RD, 392 adults with type 2 diabetes were assessed for RD, diet, exercise, medication adherence, and HbA1c at baseline and at 4 and 12 months. Associations among RD, self-management, and HbA1c were examined in cross-sectional analyses at baseline, in prospective analyses using baseline values to predict change over time, and in time-varying analyses. RESULTS At baseline, greater RD and poorer medication adherence were independently associated with higher HbA1c (P = 0.05 and P < 0.001, respectively), and greater RD was associated with poorer medication adherence (P = 0.03). No consistent pattern of significant prospective associations was found. Significant time-varying findings showed that decreases in RD were associated with improvements in medication adherence (P < 0.01), physical activity (P < 0.001), and HbA1c (P = 0.02) over time following intervention. Changes in self-management were not associated with changes in HbA1c over time. CONCLUSIONS In the context of an RCT to reduce distress, RD, self-management, and HbA1c were interrelated in cross-sectional and time-varying analyses. Decreases in RD were associated with improvements in both self-management and HbA1c over 12 months. Findings point to the complex and likely multifaceted pathways of association among these key constructs, with results indicating significant linkages between RD and both self-management and glycemic control over time.
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Abstract
OBJECTIVE To compare three interventions to reduce diabetes distress (DD) and improve self-management among non-clinically depressed adults with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS In REDEEM, 392 adults with T2DM and DD were randomized to computer-assisted self-management (CASM), CASM plus DD-specific problem solving (CAPS), or a computer-administered minimal supportive intervention. Primary outcomes were Diabetes Distress Scale (DDS) total, the Emotional Burden (EB) and Regimen Distress (RD) DDS subscales, and diet, exercise, and medication adherence. RESULTS Significant and clinically meaningful reductions in DD (DDS, EB, and RD) and self-management behaviors occurred in all three conditions (P < 0.001), with no significant between-group differences. There was, however, a significant group × baseline distress interaction (P < 0.02), in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions. RD generated the most distress and displayed the greatest distress reduction as a result of intervention. The pace of DD reduction varied by patient age: older patients demonstrated significant reductions in DD early in the intervention, whereas younger adults displayed similar reductions later. Reductions in DD were accompanied by significant improvements in healthy eating, physical activity, and medication adherence, although not by change in HbA1c. CONCLUSIONS DD is malleable and highly responsive to intervention. Interventions that enhance self-management also reduce DD significantly, but DD-specific interventions may be necessary for patients with high initial levels of DD. Future research should identify the minimal, most cost-effective interventions to reduce DD and improve self-management.
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Affiliation(s)
- Lawrence Fisher
- University of California, San Francisco, San Francisco, California, USA.
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Draznin B, Gilden J, Golden SH, Inzucchi SE, Baldwin D, Bode BW, Boord JB, Braithwaite SS, Cagliero E, Dungan KM, Falciglia M, Figaro MK, Hirsch IB, Klonoff D, Korytkowski MT, Kosiborod M, Lien LF, Magee MF, Masharani U, Maynard G, McDonnell ME, Moghissi ES, Rasouli N, Rubin DJ, Rushakoff RJ, Sadhu AR, Schwartz S, Seley JJ, Umpierrez GE, Vigersky RA, Low CC, Wexler DJ. Pathways to quality inpatient management of hyperglycemia and diabetes: a call to action. Diabetes Care 2013; 36:1807-14. [PMID: 23801791 PMCID: PMC3687296 DOI: 10.2337/dc12-2508] [Citation(s) in RCA: 119] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Currently patients with diabetes comprise up to 25-30% of the census of adult wards and critical care units in our hospitals. Although evidence suggests that avoidance of hyperglycemia (>180 mg/dL) and hypoglycemia (<70 mg/dL) is beneficial for positive outcomes in the hospitalized patient, much of this evidence remains controversial and at times somewhat contradictory. We have recently formed a consortium for Planning Research in Inpatient Diabetes (PRIDE) with the goal of promoting clinical research in the area of management of hyperglycemia and diabetes in the hospital. In this article, we outline eight aspects of inpatient glucose management in which randomized clinical trials are needed. We refer to four as system-based issues and four as patient-based issues. We urge further progress in the science of inpatient diabetes management. We hope this call to action is supported by the American Diabetes Association, The Endocrine Society, the American Association of Clinical Endocrinologists, the American Heart Association, the European Association for the Study of Diabetes, the International Diabetes Federation, and the Society of Hospital Medicine. Appropriate federal research funding in this area will help ensure high-quality investigations, the results of which will advance the field. Future clinical trials will allow practitioners to develop optimal approaches for the management of hyperglycemia in the hospitalized patient and lessen the economic and human burden of poor glycemic control and its associated complications and comorbidities in the inpatient setting.
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Affiliation(s)
- Boris Draznin
- Division of Endocrinology, Diabetes and Metabolism, University of Colorado School of Medicine, Aurora, Colorado, USA.
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Masharani U, Gjerde C, McCoy S, Maddux BA, Hessler D, Goldfine ID, Youngren JF. Chromium supplementation in non-obese non-diabetic subjects is associated with a decline in insulin sensitivity. BMC Endocr Disord 2012. [PMID: 23194380 PMCID: PMC3537689 DOI: 10.1186/1472-6823-12-31] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The use of chromium supplements is widespread for the prevention and treatment of diabetes mellitus but there are conflicting reports on efficacy, possibly reflecting discrepant effects across different populations. In the present studies, we test the hypothesis that chromium supplementation raises serum chromium levels and correspondingly improves insulin sensitivity. METHODS A double blind placebo-controlled randomized trial was conducted on 31 non-obese, normoglycemic subjects. After baseline studies, the subjects were randomized to placebo or chromium picolinate 500 μg twice a day. The primary endpoint was change in insulin sensitivity as measured by euglycemic hyperinsulinemic clamp. Pre-specified secondary endpoints included fasting lipids, blood pressure, weight, body composition measured by DXA scan. RESULTS After 16 weeks of chromium picolinate therapy there was no significant change in insulin sensitivity between groups (p=0.83). There was, however, a strong association between serum chromium and change in insulin resistance (β = -0.83, p=0.01), where subjects with the highest serum chromium had a worsening of insulin sensitivity. This effect could not be explained by changes in physiological parameters such as body weight, truncal fat and serum lipids with chromium therapy. CONCLUSIONS Chromium therapy did not improve insulin sensitivity in non-obese normoglycemic individuals. Further, subjects who have high serum chromium levels paradoxically had a decline in insulin sensitivity. Caution therefore should be exercised in recommending the use of this supplement. TRIAL REGISTRATION The study was registered on the NIH registry (clinicaltrials.gov) and the identifier is NCT00846248.
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Affiliation(s)
- Umesh Masharani
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
| | - Christine Gjerde
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
| | - Shelley McCoy
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
| | - Betty A Maddux
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
| | - Danielle Hessler
- Department of Family Medicine, University of California, San Francisco, CA, USA
| | - Ira D Goldfine
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
| | - Jack F Youngren
- Department of Medicine, Diabetes Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA, 94143-1222, USA
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