Future diabetes risk can be predicted by the number of abnormal oral glucose tolerance test values during pregnancy

AIM

To quantify the future risk of type 2 diabetes (T2D) in women with gestational diabetes (GD) based on baseline metabolic characteristics and the number of abnormal values during a 3-hour 100-g oral glucose tolerance test (OGTT).

MATERIALS AND METHODS

We conducted a population-based retrospective cohort study of 10 023 pregnant women who underwent testing for GD in a large health maintenance organization in Israel using a 100-g OGTT. Glucose values were obtained at four time points, 0, 60, 120 and 180 minutes.

RESULTS

We identified 9939 women who met the study criteria. Median follow-up was 3.25 (interquartile range 1.5-5.1; maximum 10.1) years. Using women without GD as reference, women with GD were at an increased risk of future T2D (hazard ratio [HR] 5.33 [95% confidence interval {CI} 3.86-7.34]). This risk increased with a greater number of abnormal OGTT values, with the highest risk seen in women with four abnormal values (HR 16.67 [95% CI 7.94-35.01]). In a multivariate model, a higher number of abnormal values, Arab ethnicity, higher body mass index, triglycerides and prepregnancy glucose were significantly associated with increased risk. Future T2D risk was also affected by the type of OGTT abnormality; an abnormal fasting value had the greatest risk, whereas an abnormal 3-hour value had the lowest risk (HR 3.61 [95% CI 2.42-5.38] vs. 1.50 [95% CI 0.93-2.43], respectively).

CONCLUSIONS

GD is a heterogenous disease, with varying degrees of glucose intolerance and subsequent T2D risk. Targeting interventions to women at the highest risk may help to improve postpartum adherence and effective long-term follow-up strategies.

Complex rearrangement in TBC1D4 in an individual with diabetes due to severe insulin resistance syndrome

Severe insulin resistance syndromes result from primary insulin signaling defects, adipose tissue abnormalities or other complex syndromes. Mutations in TBC1D4 lead to partial insulin signaling defects, characterized mainly by postprandial insulin resistance. We describe an individual with severe insulin-resistant diabetes unresponsive to multiple therapies, in whom exome and genome analyses identified a complex rearrangement in TBC1D4. The rearrangement was of the pattern DUP-TRP/INV-DUP, with mutational signatures suggestive of replicative repair and Alu-Alu recombination as the underlying mechanisms. TBC1D4 encodes the TBC1D4/AS160 RabGTPase activating protein (RabGAP) involved in the translocation of glucose transporter 4 (GLUT4) from the cytosol to the cell membrane. Although the precise functional mechanism underlying insulin resistance in the proband is yet to be determined, this case provides further support for the link between TBC1D4 and hereditary insulin-resistant diabetes.

GCM2 p.Tyr394Ser variant in Ashkenazi Israeli patients with suspected familial isolated hyperparathyroidism

Context

A germline mutation can be identified in up to 10% of patients with primary hyperparathyroidism (PHPT). In 2017, a high frequency of the GCM2 [(NM_ 004752.4) c.1181A> C; p.Tyr394Ser; rs142287570] variant was reported in PHPT Ashkenazi Jews (AJ).

Objective

To evaluate the presence of the GCM2 p.Tyr394Ser variant in Israeli patients addressed for genetic evaluation to characterize their phenotype and clinical management.

Method

Patients with PHPT who underwent addressed for genetic screening for suspected familial hypocalciuric hypercalcemia (FHH), a family history of isolated hyperparathyroidism (FIHP), or failed parathyroidectomy with persistent PHPT were recruited. Those with normal initial selected gene sequencing or hyperparathyroid genetic panel completed the GCM2 p.Tyr394Ser variant sequencing. The prevalence of this variant was evaluated using our local genomic database.

Results

A total of 42 single individuals from unrelated kindreds were evaluated. A disease-causing mutation was found in 11 (26.1%) patients: 10 were diagnosed with FHH (eight CASR and two AP2S1 mutations), and one patient had a CKN2B mutation. In 28 of the remaining patients, the GCM2 p.Tyr394Ser variant was positive in three (10.7%), and all were AJ. Within AJ (15/28, 53.5%), the rate of the p.Tyr394Ser variant was 3/15 (20%), and of those, two had a history of familial isolated hyperparathyroidism. Multi-glandular parathyroid adenoma/hyperplasia was also observed in two of these patients. No clinical or laboratory findings could discriminate patients with the GCM2 p.Tyr394Ser variant from those with FHH. Cinacalcet normalized the calcium levels in one patient. The prevalence of the GCM2 p.Tyr394Ser variant in 15,407 tests in our local genomic database was 0.98%.

Conclusion

In contrast to previous observations, the GCM2 p.Tyr394Ser variant-associated phenotype may be mild in AJ with FIHP, sometimes mimicking FHH. Because surgery may be curative, surgeons should be aware of the possibility of multiple gland diseases in these patients. The clinical spectrum and clinical utility of screening for this variant warrant further investigation.

RNA Sequencing Reveals Unique Transcriptomic Signatures of the Thyroid in a Murine Lung Cancer Model Treated with PD-1 and PD-L1 Antibodies

Immune checkpoint inhibitors (ICI) are commonly associated with thyroid immune-related adverse events, yet the mechanism has not been fully elucidated. We aimed to further explore the mechanism of ICI-induced thyroid dysfunction by assessing changes induced in the thyroid transcriptome by ICI treatment (αPD-1/αPD-L1) in a lung cancer murine model. RNA-sequencing of thyroid tissues revealed 952 differentially expressed genes (DEGs) with αPD-1 treatment (|fold-change| ≥1.8, FDR < 0.05). Only 35 DEG were identified with αPD-L1, and we therefore focused on the αPD-1 group alone. Ingenuity Pathway Analysis revealed that of 952 DEGs with αPD-1 treatment, 362 were associated with functions of cell death and survival, with predicated activation of pathways for apoptosis and necrosis (Z = 2.89 and Z = 3.21, respectively) and negative activation of pathways for cell viability and cell survival (Z = -6.22 and Z = -6.45, respectively). Compared to previously published datasets of interleukin-1β and interferon γ-treated human thyroid cells, apoptosis pathways were similarly activated. However, unique changes related to organ inflammation and upstream regulation by cytokines were observed. Our data suggest that there are unique changes in gene expression in the thyroid associated with αPD-1 therapy. ICI-induced thyroid dysfunction may be mediated by increased tissue apoptosis resulting in destructive thyroiditis.

Efficacy and Safety of Dapagliflozin by Baseline Insulin Regimen and Dose: Post Hoc Analyses From DECLARE-TIMI 58

OBJECTIVE

The cardiorenal benefits of adding sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy for patients on insulin, particularly those on intensive regimens that include short-acting (SA) insulin, have not been explored.

RESEARCH DESIGN AND METHODS

In Dapagliflozin Effect on Cardiovascular Events trial (DECLARE-TIMI 58), 17,160 patients with type 2 diabetes were randomized to dapagliflozin or placebo for a median follow-up of 4.2 years. Cardiovascular (CV), renal, metabolic, and safety outcomes with dapagliflozin versus placebo by insulin dose and regimen were studied with Cox regression models.

RESULTS

The study included 7,013 insulin users at baseline, with 4,650 (66.3%) patients on regimens including SA insulin. Insulin doses varied, with 2,443 (34.8%) patients receiving <0.5 IU/kg, 2,795 (39.9%) 0.5 to ≤1 IU/kg, and 1,339 (19.1%) >1 IU/kg. Dapagliflozin reduced CV death/hospitalization for heart failure among overall insulin users (hazard ratio [HR] 0.82 [95% CI 0.69-0.97]) and consistently in patients on insulin regimens with or without SA insulin (0.83 [0.67-1.03] and 0.78 [0.57-1.07], respectively, Pinteraction = 0.75). No heterogeneity was observed by insulin dose (Pinteraction = 0.43). The HR for major adverse CV events with dapagliflozin among insulin users (0.84 [0.74-0.97]) was similar irrespective of regimen or dose (Pinteraction = 0.75 and 0.07). Dapagliflozin reduced the rate of adverse renal outcomes overall and consistently across subgroups of insulin users. Decreases in HbA1c, weight, and systolic blood pressure with dapagliflozin were seen regardless of insulin dose or regimen. The known safety profile of dapagliflozin was unchanged in patients on intensive insulin regimens.

CONCLUSIONS

The benefits and safety of dapagliflozin were maintained in high-risk patients receiving high-dose or intensive insulin regimens including SA insulin.

Tumor PD-L1 expression and molecular profiling are not associated with immune checkpoint inhibitor-induced thyroid dysfunction in advanced NSCLC patients

Background: Immune-checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced non-small cell lung cancer (NSCLC), however are frequently associated with thyroid immune-related adverse events (IRAEs). We investigated the association between patient characteristics, tumor PD-L1 expression and molecular profile with the development of thyroid IRAEs in NSCLC patients. Methods: Single center, retrospective study including 107 NSCLC patients treated with PD-1/PD-L1 inhibitors from April 2016 to July 2020. All patients were euthyroid at baseline with at least two TSH measurements post-treatment initiation. The primary outcome was the difference in tumor PD-L1 expression in patients who developed any thyroid IRAEs versus those who remained euthyroid. Additional outcomes included development of overt thyroid dysfunction, the association of specific molecular alterations with thyroid IRAEs, and onset of thyroid IRAEs as a function of tumor PD-L1 expression. Results: Overall, 37 (34.6%) patients developed any thyroid dysfunction and 18 (16.8%) developed overt thyroid dysfunction. Tumor PD-L1 staining intensity was not associated with thyroid IRAEs. TP53 mutation was less likely to be associated with any thyroid dysfunction (p < 0.05) and no association was found between EGFR, ROS, ALK or KRAS mutations. There was no association between PD-L1 expression and time to develop thyroid IRAEs. Conclusion: PD-L1 expression is not associated with the development of thyroid dysfunction in advanced NSCLC patients treated with ICIs, suggesting that thyroid IRAEs are unrelated to tumor PD-L1 expression.

OR11-2 RNA Sequencing Reveals Unique Transcriptomic Signatures of the Thyroid in a Murine Lung Cancer Model Treated with PD-1 and PD-L1 Antibodies

Immune checkpoint inhibitors (ICI) have revolutionized cancer therapy, however, are associated with immune-related adverse events (irAEs). Thyroid dysfunction is among the most common irAEs, yet its mechanism has not been fully elucidated. To further explore the molecular mechanism of ICI-induced thyroid dysfunction, we profiled changes in transcription induced by PD-1/PD-L1 antibody treatment in a non-small cell lung cancer murine model using RNA-seq. We used bioinformatic tools to compare transcriptional changes in our model to previously published transcription data sets of drug-induced thyroiditis. C57BL6/129SvJ mice harboring LKR-M (Lung cancer K-ras metastatic tumor) flank tumors were treated with PD-1 antibody, PD-L1 antibody, or vehicle every 3 days over a period of 7 days when mice were sacrificed, and thyroid glands were removed. The tumor volume increased in the control mice (1.38 ± 0.19) and decreased in the anti PD-1 treated (0.64 ± 0.15; P=0.0001) and PD-L1 treated mice (0.74 ± 0.11; P=0.004). RNA-seq was performed in the LKR-M tumor-bearing control mice and in the anti PD-1/PD-L1 treated mice (n=4 per group). A total of 952 differentially expressed genes (DEGs), including 265 upregulated and 688 downregulated, were identified with anti PD-1 treatment (fold-change ≥1.8, FDR ≤0.05). Only 35 genes were differentially expressed with anti PD-L1 treatment, and we therefore chose to focus on the anti PD-1 treated group alone. Using Ingenuity Pathway Analysis (IPA), we determined that of the DEGs in the PD-1 treatment group, 362 were associated with functions of cell death and survival, with a predicated activation of pathways for apoptosis and necrosis (Z=2.89 and 3.21, respectively) and negative activation of pathways for cell viability and cell survival (Z=-6.22 and -6.45, respectively). When compared to previously published datasets of interleukin-1β and interferon gamma-treated human thyroid cells, the apoptosis pathways were similarly activated. To our knowledge this is the first study to evaluate transcriptomic changes in thyroid tissue following ICI therapy. Our data suggest that there are unique changes in gene expression in the thyroid associated with anti PD-1 therapy. ICI-induced thyroid dysfunction may be mediated by increased tissue apoptosis resulting in destructive thyroiditis.

Presentation: Sunday, June 12, 2022 11:15 a.m. - 11:30 a.m.

Low-quality employment trajectories and mental health disorders among Swedish and migrant workers

Aim

This study aims to examine the effects of low-quality employment trajectories on severe common mental disorders (CMD) according to Swedish and foreign background.

Methods

This is a longitudinal study based on Swedish population registries (N = 2,703,687). Low- and high-quality employment trajectories observed across five years (2005-2009) are the exposure with severe CMD as outcome (2010-2017). Adjusted hazard ratios (HR) were calculated using Cox regression stratified according to background (first-generation (i) EU migrants, (ii) non-EU migrants, (iii) second-generation migrants, (iv) Swedish-born with Swedish background) and sex. The reference group were Swedish-born with Swedish background in a Constant high-quality employment trajectory.

Results

Second-generation migrants had an increased risk of CMD compared to Swedish-born with Swedish background when following low-quality employment trajectories (e.g., male in Constant low-quality HR: 1.53, 95% CI: 1.41-1.68). Female migrant workers, especially first-generation from non-Western countries in low-quality employment trajectories (e.g., Constant low-quality HR: 1.65, 95% CI:1.46 - 1.87), had a higher risk of CMD compared to female Swedish-born with Swedish background. The confidence interval for CMD risk showed little differences between migrant groups (1st and 2nd generation) compared to the reference group.

Conclusions

Low-quality employment trajectories appear to be determinants of risk for CMD, having a differential impact according to background of origin and sex. We observe a higher risk for severe CMD across migrant groups, especially second-generation migrants, compared to Swedish-born with Swedish background. Further qualitative research is recommended to understand the mechanism behind the differential mental health impact of low-quality employment trajectories according to foreign background.

Key messages

• First and second-generation migrants in low quality employment have higher risk of severe common mental disorders compared to Swedish born with Swedish background workers in low quality employment.

• Policies targeting working conditions in low-quality employment and promoting workers mental well-being are essential to reduce this higher risk for developing CMD, especially for migrant populations.

Consistency of TI-RADS Reporting in Community-Based Imaging Centers vs. a Large Tertiary Hospital

OBJECTIVE

In our country, thyroid nodules are sonographically evaluated in health maintenance organization (HMO) imaging centers, and patients are referred to tertiary hospitals for ultrasound-guided fine needle aspiration (FNA) biopsy when indicated. We evaluated the concordance in Thyroid Imaging Reporting and Data System (TI-RADS) classification reporting between these sites.

METHODS

We conducted a retrospective cohort study reviewing the sonographic features of thyroid nodules evaluated both at the HMO and a large tertiary center between January 2018 and December 2019. The primary outcome was concordance between the TI-RADS classification at both sites. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA and correlation of TI-RADS with malignancy on final pathology at each site.

RESULTS

The records of 336 patients with 370 nodules were reviewed. The level of concordance was poor (19.8%), with 277 (74.8%) nodules demonstrating higher TI-RADS and 20 (5.4%) lower TI-RADS at the HMO compared to the hospital (p<0.001, weighted Kappa = 0.120). FNA results were available for 236 (63.8%) nodules. The Bethesda category strongly correlated with the hospital TI-RADS (p<0.001), yet not with HMO TI-RADS (p=0.123). In the 57 nodules surgically removed, a strong correlation was identified between malignancy on final pathology and TI-RADS documented at the hospital (p<0.001), yet not at the HMO (p=0.259).

CONCLUSIONS

There is poor agreement between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. The hospital TI-RADS strongly correlated with Bethesda category and final risk of malignancy unlike the HMO.

[IMMUNE CHECKPOINT INHIBITOR-INDUCED DIABETES MELLITUS]

Immune checkpoint inhibitors (ICIs) have transformed the care of cancer patients, providing therapeutic options for advanced malignancies considered otherwise untreatable. However, these agents have been associated with immune-related adverse events (irAEs). ICI-induced diabetes (ICI-DM) is a rare complication of programmed death-1 (PD-1) or programmed death-ligand 1 (PD-L1) inhibitor therapy (~1%) and can be life-threatening, as patients often present with severe hyperglycemia and in diabetic ketoacidosis. We describe two patients with rapid-onset diabetes mellitus associated with anti PD-1 therapy followed by an in-depth review of the literature. We discuss the clinical presentation, potential mechanisms and optimal management of patients with ICI-DM. As ICI use continues to expand across a wide variety of malignancies, clinicians must be aware of this potentially life-threatening irAE to prevent significant morbidity and mortality.

Interobserver Variability in Ultrasound Reporting - Tertiary Hospital Radiologists Do Better

Introduction: Thyroid Imaging Reporting and Data System (TI-RADS) was developed to provide a standardized risk-stratification system for patients with thyroid nodules. Single-center studies have demonstrated an acceptable level of interobserver agreement in applying TI-RADS in clinical practice, however data regarding consistency among different centers is limited. In Israel, thyroid nodules are initially evaluated by ultrasound performed by radiologists at the health maintenance organization (HMO) and then patients are referred to tertiary hospitals for ultrasound-guided fine needle aspiration (FNA) biopsy when indicated. Objective: To evaluate the interobserver concordance in TI-RADS classification system reporting between the HMO and a tertiary hospital. Methods: We performed a retrospective analysis of the sonographic features of 370 thyroid nodules TI-RADS category 2 or higher, from 350 patients evaluated by ultrasound at the HMO and at Hadassah Medical Center from January 1, 2018 to December 31, 2019. The primary outcome was concordance between the TI-RADS classification at the HMO compared to the hospital. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA, and correlation of TI-RADS with malignancy on final pathology. Results: Of 370 nodules, only 73 (19.8%) demonstrated concordance between the HMO and the hospital. The level of agreement was poor, with 277 (74.8%) nodules demonstrating higher TI-RADS at the HMO compared to the hospital, and 20 (5.4%) with lower TI-RADS at the HMO compared to the hospital (p&lt;0.001, weighted Kappa = 0.120). Of the nodules referred to the hospital, 241 (65.1%) were selected for FNA. A strong correlation between the hospital TI-RADS and Bethesda category was demonstrated (p&lt;0.001). Furthermore, 60 (16.2%) nodules were surgically removed. A strong correlation was identified between the hospital TI-RADS and malignancy on final pathology (p&lt;0.001), yet there was no correlation with the TI-RADS of the HMO (p=0.346). Conclusions: There is poor concordance between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. In patients who underwent FNA and eventually surgery, the hospital TI-RADS strongly correlated with Bethesda category and final risk of malignancy. Standardization of thyroid ultrasound terminology and dedicated training in thyroid imaging are needed to improve the interobserver concordance in clinical practice.

Role of Cannulated Prolactin Test in Evaluation of Hyperprolactinemia - A Retrospective Study

OBJECTIVE

While guidelines propose a single elevated prolactin measurement drawn without excess venipuncture stress as sufficient for diagnosing hyperprolactinemia, this may lead to unnecessary evaluation in the setting of stress-induced hyperprolactinemia. In this study, we aimed to define the role of the cannulated prolactin test in confirming hyperprolactinemia.

METHODS

We conducted a retrospective review of 757 patients with unexplained hyperprolactinemia who performed a cannulated prolactin test in a community-based referral endocrine clinic between 2000-2015. The prolactin test consisted of "test-baseline" levels taken at rest (T0), and cannulated measurements at 60 and 90 minutes (T60 and T90) without repeated venipuncture. The most recent prolactin level performed prior to the test (referral-prolactin) was collected.

RESULTS

Referral-prolactin was available for 621 (82%) patients, of whom 324 (52.2%) normalized at T0. The probability of normoprolactinemia at T0 was 50% if referral-prolactin was 2.0-fold the upper-limit-of-normal (ULN), yet only 5% if referral-prolactin was 5.0-fold the ULN. Of the 359 patients with hyperprolactinemia at T0, prolactin normalized at T60 and/or T90 in 99 (27.6%) patients. The probability of normoprolactinemia was low (<5%) in those with T0 prolactin levels >2.4-fold ULN. Overall, of 757 prolactin tests performed, only 260 (34.3%) patients had persistent hyperprolactinemia.

CONCLUSION

Patients with referral-prolactin levels >5.0-fold the ULN, or a rested-prolactin (T0) >2.4-fold the ULN are unlikely to normalize during the cannulated test and consideration should be made to proceed directly with pituitary imaging. In patients with prolactin levels below these thresholds, the cannulated prolactin test may considerably reduce unnecessary investigations, treatment, and cost.

Impact of flash glucose monitoring on glucose control and hospitalization in type 1 diabetes: A nationwide cohort study

BACKGROUND

We evaluated the impact of flash continuous glucose monitoring (FCGM) on glycemic control and healthcare burden in a large real-world cohort of patients with type 1 diabetes (T1D) initiating FCGM technology.

METHODS

In this retrospective cohort study, we included adults (age ≥18 years) with T1D from a large Health Maintenance Organization in Israel, who initiated FCGM during 2018. Primary outcomes included change in HbA1c ≥3 months following FCGM commencement and change in rate of internal-medicine hospitalization. Additional outcomes included changes in glucose test strip purchases, diabetes related outpatient health care visits and hospitalization for diabetic ketoacidosis (DKA) and/or severe hypoglycemia.

RESULTS

The study included 3490 patients, followed for a median of 14 (inter-quartile range 11-15) months after FCGM commencement. Among 2682 patients with an HbA1c measured both at baseline and ≥3 months after FCGM initiation, average HbA1c declined from 8.1% ± 1.46% to 7.9% ± 1.31% (P < .001) at first measurement and was maintained during follow up. Specifically, in those with HbA1c ≥8%, a mean decline of 0.5% (P < .001) was observed. A clinically significant HbA1c reduction of ≥0.5% was experienced by 25.5% of the patients. The rate of internal medicine hospitalization, visits to primary care, or visits to endocrine/diabetes specialists in the period following FCGM commencement vs the 6 months prior was significantly reduced (P < .001). Hospitalization for DKA and/or hypoglycemia declined as well (P = .004).

CONCLUSIONS

FCGM was associated with significant and durable improvement in glycemic control as well as reduced consumption of healthcare services.

Active Surveillance of Thyroid Microcarcinoma-Can This Approach Be Safely Implemented Worldwide?

The incidence of thyroid cancer has been increasing exponentially worldwide, mainly due to increased detection of small papillary thyroid microcarcinomas (PTMCs). Given the indolent nature of the disease, active surveillance (AS) has been suggested as an alternative approach to immediate surgery in the management of low-risk PTMCs. The decision to proceed with AS must take into account patient characteristics, tumor characteristics, and medical team characteristics. In this review, we discuss the rationale and evidence to support AS, as well as important considerations and limitations to implementing this approach for PTMC worldwide.

Immune Checkpoint Inhibitor-induced Thyroid Dysfunction Is Associated with Higher Body Mass Index

CONTEXT

Obesity is a proinflammatory metabolic state that may play a role in the development of immune-related adverse events (irAEs) associated with immune checkpoint inhibitor therapy.

OBJECTIVE

To characterize the association between body mass index (BMI) and thyroid irAEs.

METHODS

We performed a single-center, retrospective analysis of 185 cancer patients treated with anti-PD-1/L1 from January 2014 to December 2018. Patients with normal thyroid function at baseline and available BMI were included.

MAIN OUTCOME MEASURES

The primary endpoint was difference in BMI in patients who developed overt thyroid dysfunction versus those who remained euthyroid following anti-PD-1/L1 initiation. Additional endpoints included any (overt or subclinical) thyroid dysfunction, overt thyrotoxicosis or overt hypothyroidism, and time to development of dysfunction according to BMI.

RESULTS

Any thyroid dysfunction developed in 72 (38.9%) patients and 41 (22.1%) developed overt thyroid dysfunction. Mean BMI was higher in those with overt thyroid dysfunction versus euthyroid (27.3 ± 6.0 vs 24.9 ± 4.5, P = .03). Development of overt thyrotoxicosis versus remaining euthyroid was associated with higher BMI (28.9 ± 5.9 vs 24.9 ± 4.5; P < .01), whereas overt hypothyroidism was not (26.7 ± 5.5 vs 24.9 ± 4.5, P = .10). Overt thyrotoxicosis developed within 57.5 (interquartile range [IQR] 31.8-78.8) days of treatment in the low-normal BMI group, 38.0 (IQR 26.8-40.5) days in the overweight group, and 23.0 (IQR 21.0-28.0) days in the obese group (P = .02).

CONCLUSIONS

Patients treated with PD-1/L1 inhibitors were more likely to develop thyroid irAEs, specifically overt thyrotoxicosis, with increasing BMI. Overt thyrotoxicosis occurred earlier in obese versus leaner patients. These data highlight the complex interplay between obesity and immune response in immune checkpoint inhibitor-treated patients.

OR28-07 Increased BMI Is Associated With Anti PD-1/PD-L1-Induced Thyroid Immune-Related Adverse Events

Background: Immune checkpoint inhibitors have revolutionized cancer therapy, however, are associated with immune related adverse events (irAEs). Obesity is a pro-inflammatory metabolic state that may play a role in the development of irAEs. Hypothesis: We hypothesized that likelihood of developing thyroid irAEs following anti-PD-1/L1 therapy increases with increasing body mass index (BMI). Methods: We retrospectively analyzed data of 187 cancer patients who initiated anti-PD-1/L1 at our institution between 01/2014-12/2018, had normal thyroid function tests at baseline and had baseline BMI data available. Results: Overall, 97 (52.2%) patients were with low-normal BMI (<25 kg/m²), 52 (28.0%) overweight (≥25-30 kg/m²) and 37 (19.9%) obese (≥30 kg/m²). Thyroid dysfunction (hyper or hypo, overt or subclinical) developed in 72/187 (38.7%) patients, of whom 29/97 (29.9%) had low-normal BMI, 22/52 (42.3%) were overweight and 21/37 (56.8%) obese (p=0.14). With every 1 kg/m² increase in BMI, the likelihood of thyroid dysfunction increased by 8.8% (p=0.004). Overt hyperthyroidism occurred in 32/186 (9.1%) of the patients - in 4.1% of patients with low-normal BMI, 11.5% of overweight patients and 18.9% of obese (p=0.006). Overt hypothyroidism occurred in 32/186 (17.2%) of the patients and was not significantly associated with BMI. Hyperthyroidism followed by overt hypothyroidism, consistent with thyroiditis, occurred in 13/186 (7.0%) of patients and was significantly associated with increasing BMI category (p=0.03). Conclusions: Increased BMI was associated with increased thyroid irAEs in patients treated with PD-1/L1 inhibitors. Further exploration of the interaction between obesity and immunotherapy may provide insight into the role of inflammation in mediating immune response.

Association of Inpatient Glucose Measurements With Amputations in Patients Hospitalized With Acute Diabetic Foot

CONTEXT

The association of inpatient glucose measurements with amputations in patients admitted with acute diabetic foot has not been described.

OBJECTIVE

To evaluate the relationship of hyperglycemia, hypoglycemia, and glucose variability during hospitalization with amputations in patients hospitalized with acute diabetic foot.

DESIGN

Retrospective cohort study.

SETTING

Academic tertiary hospital.

PATIENTS

We reviewed demographic, clinical, laboratory, and point-of-care glucose data in patients hospitalized with acute diabetic foot in the Diabetic Foot Unit during 2015 through 2017.

MAIN OUTCOME MEASURES

The primary outcomes were any or major amputations during hospitalization. Secondary outcomes included length of hospitalization and in-hospital mortality.

RESULTS

During the study period, 418 patients were hospitalized in the Diabetic Foot Unit and 45,496 glucose measurements were taken. Patients experiencing any hyperglycemia and any or severe hypoglycemia were more likely to undergo any or major amputations during hospitalization. High glycemic variability was associated with major amputations. Peripheral vascular disease (PVD), high Wagner score, and hypoglycemia were independent predictors of amputations. Older age, PVD, previous amputation, elevated white blood cell level, high Wagner score, and hypoglycemia were independent predictors of major amputations.

CONCLUSIONS

In-patient hypoglycemia emerged as an independent risk factor for any and major amputations. Although it is unclear whether hypoglycemia directly contributes to adverse outcomes or is simply a biomarker of disease severity, efforts to minimize in-hospital hypoglycemic events are warranted.

MON-LB008 PD-L1 Expression in Normal Endocrine Tissues

Introduction: Immune checkpoint inhibitor (ICI) therapy, including cytotoxic T-lymphocyte-associated protein 4 (CLTA-4) and programmed cell death 1 (PD-1) inhibitors, is revolutionizing cancer treatment. However, these agents are associated with immune-related adverse events (irAEs), most commonly endocrine-related. Hypophysitis, thyroid dysfunction, insulin-deficient diabetes mellitus and primary adrenal insufficiency have been reported as irAEs due ICI therapy. The precise mechanisms underlying these endocrine irAEs remain to be elucidated. Aim: In this study, we evaluated patterns of programmed cell death ligand 1 (PD-L1) expression in normal endocrine tissues to determine whether increased expression may explain the predilection of endocrinopathies in patients treated with PD-1 inhibitors. Methods: Immunohistochemical (IHC) analysis using the Ventana 22C3 PD-L1 IHC platform was performed on normal FFPE endocrine tissue samples stored in our hospital pathology tissue archive. Results: Five samples from each organ including pituitary, thyroid, parathyroid, adrenal and pancreas were examined. Focal membranous PD-L1 positivity was noted in the normal pituitary tissues, but was negative in normal thyroid, parathyroid, adrenal and pancreatic tissues. Conclusions: Majority of normal endocrine tissues do not demonstrate increased PD-L1 expression. Our limited data so far does not support the hypothesis that increased PD-L1 expression in endocrine tissues is associated with the endocrine irAEs following anti PD-1 therapy. The increased predilection of endocrinopathies in patients treated with anti PD-1 inhibitors seems to be via alternate pathways. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Acute renal outcomes with sodium-glucose co-transporter-2 inhibitors: Real-world data analysis

AIM

To assess the possible risk of acute kidney injury (AKI) with the use of sodium-glucose co-transporter-2 inhibitors (SGLT2-i) as well as changes in estimated glomerular filtration rate (eGFR), hospitalizations and mortality in a real-world setting.

MATERIALS AND METHODS

Included in this historical cohort study were patients with type 2 diabetes in a large health organization in Israel who initiated therapy with SGLT2-i or dipeptidyl peptidase-4 inhibitors (DPP-4i) during 1 April 2015 to 30 June 2017. We collected data on serum creatinine measurements taken between 180 days prior to and 24 weeks after therapy initiation. Study endpoints included ≥30% reduction in eGFR, hospitalization with AKI, any hospitalization and all-cause mortality.

RESULTS

Overall 6418 and 5604 patients initiated SGLT2-i and DPP-4i, respectively. Baseline mean (SD) eGFR was higher among the SGLT2-i group compared with the DPP-4i group (88.3 [17.4] and 82.8 [23.7], respectively) but were similar when stratifying by chronic kidney disease (CKD) stages. The adjusted odds ratio (OR) (95% confidence interval [CI]) for ≥30% reduction in eGFR with SGLT2-i versus DPP4-i was 0.70 (0.49-1.00) and ORs ranged from 1.97 (0.62-6.26) to 0.45 (0.21-0.99) in patients with baseline eGFR 30 to 45 and ≥90 mL/min/1.73 m² , respectively. Risks of AKI (OR = 0.47, 95% CI 0.27-0.80), hospitalization (OR = 0.66, 95% CI 0.56-0.78) or all-cause mortality (OR = 0.43, 95% CI 0.20-0.95) were lower in patients initiating SGLT2-i versus DPP-4i.

CONCLUSIONS

This real-world data analysis supports reassuring findings from previous randomized clinical trials showing no increased AKI risk among SGLT2-i users. Nevertheless, because of the more prominent decrease in eGFR in patients with moderate CKD, cautious use of SGLT2-i in patients with reduced eGFR is advised.

Validity of diagnostic codes and estimation of prevalence of diabetic foot ulcers using a large electronic medical record database

AIMS

To assess the validity of the diagnostic codes relating to diabetic foot ulcer (DFU) in the electronic medical records of a large integrated care provider and to assess the prevalence of DFU among its members.

MATERIALS AND METHODS

Data were obtained from the diabetes registry of Maccabi Healthcare Services (MHS), a 2.1-million-member sick-fund in Israel, which included 125 665 patients in 2015. We randomly selected and reviewed ~400 patient files from each of the following categories during study period: (1) had a diagnostic code of DFU; (2) had a diagnostic code, or clinical condition suggestive of DFU including: leg-ulcer, amputation, DFU in quartiles proximate to 2015 or abnormality reported by nurse; (3) patients at high risk for DFU (age > 35 and one of the following: peripheral artery disease, neuropathy, DFU during 2011-2014, eGFR<30 mL/min/m² or foot deformity). The patients' charts were reviewed by study physicians, and DFU was validated or refuted.

RESULTS

Relying upon diagnostic codes entered by physicians, the positive predictive value (PPV) was 73.1% (95% CI 67.6-78.2), and the sensitivity was 48.2% (95% CI 45.8-50.7%). The PPV of the diagnostic codes listed by podiatrists were significantly lower, while that of codes listed by nurses was higher but with lower sensitivity. The estimated annual prevalence of DFU in the diabetes registry of MHS was 1.2% (95%CI 1.0-1.5%).

CONCLUSIONS

Diagnostic codes alone cannot be used reliably to create a DFU registry. Nevertheless, the data collected provide an estimate of the prevalence of DFU among patients included in the MHS diabetes registry.

Treatment of Type 2 Diabetes: From "Guidelines" to "Position Statements" and Back: Recommendations of the Israel National Diabetes Council

Given the increased prevalence of type 2 diabetes worldwide, most patients are treated by their primary health care team (PHCT). PHCTs need guidance in choosing the best treatment regimen for patients, since the number of glucose-lowering agents (GLAs) is rapidly increasing, as is the amount of clinical data regarding these drugs. The American Diabetes Association/European Association for the Study of Diabetes Position Statement emphasizes the importance of personalized treatment and lists drug efficacy, risk of hypoglycemia, effect on weight, side effects, and cost as important parameters to consider when choosing GLAs. The suggested Israeli guidelines refocus earlier international recommendations from 2012 and 2015, based on emerging data from cardiovascular outcome trials as well as what we believe are important issues for patient care (i.e., durability, hypoglycemia risk, and weight gain).

Assessing impaired glucose tolerance and insulin resistance in polycystic ovarian syndrome with a muffin test: an alternative to the glucose tolerance test

OBJECTIVE

To determine the sensitivity of a high-glucose load in a meal as an alternative to the standard oral glucose tolerance test (OGTT) in detecting impaired glucose tolerance and insulin resistance in women with polycystic ovarian syndrome (PCOS) and the relationship of body composition to insulin resistance in the PCOS cohort.

METHODS

In this prospective, single-center study, women with PCOS who were being followed up as out-patients were recruited. The study was performed between November 2007 and March 2008. All participants underwent OGTT before study enrollment. Participants were given a meal including carbohydrates, fat, and protein. Glucose and insulin levels were measured every 30 minutes for 2 hours after completing the meal. Body composition was measured by dual-energy x-ray absorptiometry.

RESULTS

Thirteen of the 15 participants completed the meal tolerance test and the body composition study. Four of 13 participants (31%) had abnormal glucose tolerance with the meal test compared with 2 of 8 participants (25%) who completed the OGTT. Those who had insulin resistance on OGTT were detected with the meal test. The 2-hour insulin levels following the meal were 38% higher than with the OGTT. Of 10 participants with insulin resistance, 9 had a total body fat mass greater than the 90th percentile, whereas 1 of 3 participants (33%) with normal body composition was insulin resistant.

CONCLUSION

Administration of oral glucose load via a meal is an effective alternative to the OGTT in diagnosing impaired glucose tolerance and insulin resistance and may be more sensitive, without the adverse effects of the oral glucose load in the OGTT. PCOS is an independent risk factor for impaired glucose tolerance and insulin resistance, regardless of body composition.

Some practical suggestions for teaching science in the liberal arts

At the undergraduate level, science is held at a distance from the liberal arts by common agreement among professors from both sides of a wall erected for them by the Enlightenment some centuries ago. There is today no intellectual argument put forth for maintaining the wall; the arguments in its defense are largely cultural and political and therefore in the final analysis fiscal, if not venal. Here are some concrete suggestions for how that wall might be brought down.

Prospective comparison between laparoscopic preperitoneal herniorrhaphy and open mesh herniorrhaphy

Controversy persists regarding the most effective inguinal hernia repair. The purpose of this study is to compare the complications, charges, patient satisfaction, and recovery time between laparoscopic (LH) and open mesh herniorrhaphy (OH). A nonrandomized prospective analysis of 233 consecutive inguinal hernia repairs was performed over a 12-month period by 27 surgeons. The type of repair was determined by surgeon preference. Cost analysis was performed using anesthesia records and hospital cost. Patient satisfaction and recovery time were evaluated by third-party interview. A total of 113 OHs and 120 LHs were performed; 11 OHs and 42 LHs were bilateral. Patient demographics were equivalent for the two groups. No statistical difference was noted when comparing anesthesia/operating room time between the two groups. The LHs accrued an additional charge of $2254 per case. Complication rates were 4.4 per cent for the OHs and 8.3 per cent for the LHs. All complications were considered minor. No infectious complications or recurrences were noted in either group. Satisfaction rates and pain indices were nearly identical for both OHs and LHs. The LHs had a shorter recovery time by 5.5 days. We conclude that LH is associated with a higher complication rate and cost than OH. Pain indices are similar, but LH has a shorter recovery time.

Appearance of the uterus by ultrasound immediately after placental delivery with pathologic correlation

The purpose of this study was to compare the ultrasound appearance of the uterus immediately after the placenta was delivered with the gross and histologic findings obtained by manual exploration and sponge curettage. One hundred thirty-one patients underwent a sonographic assessment of the uterus within 5 minutes of placental delivery. A manual exploration and sponge curettage were performed with 2 minutes of the ultrasound examination, and the specimens were assessed for gross and histologic evidence of retained products of conception. Twenty-four (18.8%) of the patients had documented evidence of retained products of conception either by gross inspection or histologic assessment. Nineteen (15%) of the patients had what appeared to be retained products on ultrasound examination. Using our sonographic description of retained products of conception, the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound in detecting retained products was 44%, 92%, 58%, and 87%, respectively. The ultrasound findings in patients with retained products of conception were: a normal endometrial cavity in 9 (37.5%), echogenic mass in 6 (25%), heterogenous mixed density mass in 5 (21%), and fluid only in 4 (16.6%). Of the 6 cases with an echogenic mass, all were associated with retained products of conception. The ultrasound appearance of retained products of conception in the immediate time period after placental delivery is highly variable.

Etiologic determinants of abruptio placentae

OBJECTIVE

To quantify the roles of suspected sociodemographic, anthropometric, behavioral, and pathologic determinants in the etiology of abruptio placentae.

METHODS

We performed a hospital-based cohort study of 36,875 nonreferred births between January 1978 and March 1989. Gestational age was based on menstrual dates confirmed (within 7 days) by early ultrasound.

RESULTS

Parity, maternal education, pre-pregnancy weight, and the rate of net gestational weight gain did not have significant independent associations with abruption. Significant determinants included the following: severe small for gestational-age (SGA) birth (odds ratio [OR] 3.99; 95% confidence interval [CI] 2.75, 5.77), chorioamnionitis (OR 2.50; 95% CI 1.58, 3.98), prolonged rupture of membranes (OR 2.38; 95% CI 1.55, 3.65), preeclampsia (OR 2.05; 95% CI 1.39, 3.04), pregnancy-induced hypertension without albuminuria (OR 1.57; 95% CI 1.00, 2.46), pre-pregnancy hypertension (OR 1.77; 95% CI 1.05, 2.99), maternal age at least 35 years (OR 1.50; 95% CI 1.14, 2.01), unmarried status (OR 1.50; 95% CI 1.13, 1.98), cigarette smoking (OR 1.40; 95% CI 1.00, 1.97 for ten to 19 cigarettes per day and OR 1.13; 95% CI 0.81, 1.59 for at least 20 cigarettes per day), and male fetal gender (OR 1.38; 95% CI 1.12, 1.70). Removal of SGA from the regression model resulted in little change in the magnitude of the other associations.

CONCLUSIONS

Severe fetal growth restriction, prolonged rupture of membranes, chorioamnionitis, hypertension (before pregnancy and pregnancy-induced), cigarette smoking, advanced maternal age, unmarried status, and male fetal gender are significant etiologic determinants of placental abruption. Non-SGA determinants appear to operate largely independently of their effects on fetal growth.

Concurrent Lyme disease and babesiosis. Evidence for increased severity and duration of illness

OBJECTIVE

To determine whether patients coinfected with Lyme disease and babesiosis in sites where both diseases are zoonotic experience a greater number of symptoms for a longer period of time than those with either infection alone.

DESIGN

Community-based, yearly serosurvey and clinic-based cohort study.

SETTING

Island community in Rhode Island and 2 Connecticut medical clinics from 1990 to 1994.

STUDY PARTICIPANTS

Long-term residents of the island community and patients seeking treatment at the clinics.

MAIN OUTCOME MEASURES

Seroreactivity to the agents of Lyme disease and babesiosis and number and duration of symptoms.

RESULTS

Of 1156 serosurvey subjects, 97 (8.4%) were seroreactive against Lyme disease spirochete antigen, of whom 14 (14%) also were seroreactive against babesial antigen. Of 240 patients diagnosed with Lyme disease, 26 (11%) were coinfected with babesiosis. Coinfected patients experienced fatigue (P = .002), headache (P < .001), sweats (P < .001), chills (P = .03), anorexia (P = .04), emotional lability (P = .02), nausea (P = .004), conjunctivitis (P = .04), and splenomegaly (P = .01) more frequently than those with Lyme disease alone. Thirteen (50%) of 26 coinfected patients were symptomatic for 3 months or longer compared with 7 (4%) of the 184 patients with Lyme disease alone from whom follow-up data were available (P < .001). Patients coinfected with Lyme disease experienced more symptoms and a more persistent episode of illness than did those (n = 10) experiencing babesial infection alone. Circulating spirochetal DNA was detected more than 3 times as often in coinfected patients as in those with Lyme disease alone (P = .06).

CONCLUSIONS

Approximately 10% of patients with Lyme disease in southern New England are coinfected with babesiosis in sites where both diseases are zoonotic. The number of symptoms and duration of illness in patients with concurrent Lyme disease and babesiosis are greater than in patients with either infection alone. In areas where both Lyme disease and babesiosis have been reported, the possibility of concomitant babesial infection should be considered when moderate to severe Lyme disease has been diagnosed.

Dental office ergonomics: how to reduce stress factors and increase efficiency

Ergonomics, the science that studies human stress and strain related to activities, has one primary objective-to prevent work related musculoskeletal disorders, or symptoms that aggravate these disorders. Smart business owners have adopted the practice of ergonomics as an integral element in their ongoing strategies to increase productivity and ensure reduced workers' compensation liability. In British Columbia, however, potentially expensive ergonomic draft regulations created by the province's Workers' Compensation Board in 1993, have been put on hold. These ergonomic standards-described as the stiffest in the world -were to have been implemented across the province in early 1995. Nonetheless, ergonomic practices are alive and thriving in Canadian businesses that are devoted to ensuring a reduction in work-related injuries and salvaging potentially lost productivity. Although it is difficult to document lost productivity, Ontario's Workers' Compensation Board reported that it received 707 repetitive stress injury claims from office workers in 1992, with a per person cost of $7,703. In addition to these costs, each claimant took about 93 days off work. In dentistry, poor working habits, along with repetitive tasks, such as scaling and root planing, contribute greatly to musculoskeletal disorders, stress claims and lost productivity. Our tendency is to adapt awkward and illogical physical postures to access the oral cavity. The key objective for clinicians is to find a position that allows them to achieve optimum access, visibility, comfort and control at all times. With the professional goal to deliver the highest quality of care for a reasonable profit, the practice of ergonomics becomes a core focus in determining how to achieve practice success with less stress.

Dento-ergonomics: the key to energy-saving performance

The application of ergonomics to dentistry, or dento-ergonomics, can increase efficiency and prevent injury. Among the factors that need to be considered are the height and reach of staff members, the equipment being used and the distribution of tasks. By implementing the theories of ergonomics, dental care providers can prolong their interest and commitment to dentistry by making difficult or even painful tasks less stressful.