Fulminant type 1 diabetes, an underrecognized and unique subtype of type 1 diabetes: A case series from Singapore

Fulminant type 1 diabetes (FT1D) is a unique subtype of type 1 diabetes, characterized by acute absolute insulin deficiency, severe ketosis, and increased risk of hypoglycemia, glycemic variability and microvascular complications. Seven people with FT1D were identified from two tertiary centers in Singapore. Six were Chinese, the mean age was 35 years and all were lean (mean body mass index 20.3 kg/m2 ). All presented with diabetes ketosis or ketoacidosis and low C-peptide. All but one had low glutamic acid decarboxylase antibodies. Nearly half had a missed/delayed diagnosis of FT1D. Three had frequent hypoglycemia, which improved after transition to continuous subcutaneous insulin infusion therapy. Individuals with FT1D experience unique diagnostic and management challenges associated with rapid absolute insulin deficiency. Greater awareness about this clinical entity is required.

Case Report: Hypercalcemia as a manifestation of acute adrenal crisis precipitated by fluconazole use, and a review of the literature

Acute adrenal crisis classically presents with vomiting, altered sensorium, and hypotension. We describe a unique case manifesting with severe hypercalcemia. Addisonian crisis was unusually precipitated by fluconazole use. We reviewed other reported cases and discuss the possible mechanisms of hypercalcemia in adrenal insufficiency. This 67-year-old man presented with fever, cough, and vomiting for 1 week and with anorexia and confusion for 3 weeks. He was hypotensive and clinically dehydrated. Investigations revealed left-sided lung consolidation, acute renal failure, and severe non-parathyroid hormone (PTH)-mediated hypercalcemia (calcium, 3.55mol/L; PTH, 0.81pmol/L). Initial impression was pneumonia complicated by septic shock and hypercalcemia secondary to possible malignancy. He received mechanical ventilation; treatment with intravenous fluids, inotropes, and hydrocortisone for septic shock; and continuous renal replacement therapy with low-calcium dialysate. Although hypercalcemia resolved and he was weaned off inotropes, dialysis, and hydrocortisone, his confusion persisted. When hypercalcemia recurred on day 19 of admission, early morning cortisol was <8 nmol/L, with low ACTH level (3.2 ng/L). Other pituitary hormones were normal. Hypercalcemia resolved 3 days after reinstating stress doses of hydrocortisone, and his mentation normalized. On further questioning, he recently received fluconazole for a forearm abscess. He previously consumed traditional medications but stopped several years ago, which may have contained glucocorticoids. He was discharged on oral hydrocortisone. Cortisol levels improved gradually, and glucocorticoid replacement was ceased after 8 years, without any recurrence of hypercalcemia or Addisonian crisis. Both hypercalcemia and adrenal insufficiency may present with similar non-specific symptoms. It is important to consider adrenal insufficiency in hypercalcemia of unclear etiology.

Treatment of Primary Aldosteronism and Reversal of Renin Suppression Improves Left Ventricular Systolic Function

INTRODUCTION

Primary aldosteronism (PA) is associated with increased risk of cardiovascular events. However, treatment of PA has not been shown to improve left ventricular (LV) systolic function using the conventional assessment with LV ejection fraction (LVEF). We aim to use speckle-tracking echocardiography to assess for improvement in subclinical systolic function after treatment of PA.

METHODS

We prospectively recruited 57 patients with PA, who underwent 24-h ambulatory blood pressure (BP) measurements and echocardiography, including global longitudinal strain (GLS) assessment of left ventricle, at baseline and 12 months post-treatment.

RESULTS

At baseline, GLS was low in 14 of 50 (28.0%) patients. On multivariable analysis, GLS was associated with diastolic BP (P = 0.038) and glomerular filtration rate (P = 0.026). GLS improved post-surgery by -2.3, 95% CI: -3.9 to -0.6, P = 0.010, and post-medications by -1.3, 95% CI: -2.6 to 0.03, P = 0.089, whereas there were no changes in LVEF in either group. Improvement in GLS was independently correlated with baseline GLS (P < 0.001) and increase in plasma renin activity (P = 0.007). Patients with post-treatment plasma renin activity ≥1 ng/ml/h had improvements in GLS (P = 0.0019), whereas patients with persistently suppressed renin had no improvement. Post-adrenalectomy, there were also improvements in LV mass index (P = 0.012), left atrial volume index (P = 0.002), and mitral E/e' (P = 0.006), whereas it was not statistically significant in patients treated with medications.

CONCLUSION

Treatment of hyperaldosteronism is effective in improving subclinical LV systolic dysfunction. Elevation of renin levels after treatment, which reflects adequate reversal of sodium overload state, is associated with better systolic function after treatment.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, identifier: NCT03174847.

POS1460-HPR MYRA TOUCH FOR DISEASE ACTIVITY EVALUATION IN RHEUMATOID ARTHRITIS: A COMPARISON OF PATIENT-REPORTED OUTCOMES WITH PHYSICIAN’S ASSESSMENT

Background:

Patient-reported outcomes (PROs) have become an essential component of patients’ assessment in the management of Rheumatoid Arthritis(RA).They have been reported to be at least as informative if not more than physician assessed outcomes.

MyRA Touch was pioneered by the Rheumatology Unit of Hospital Tuanku Jaa’far in Seremban Malaysia in March 2018,to engage and empower all RA patients on their own disease activity monitoring. It is an electronic platform, designed to enhanced the application of electronic patient reported outcomes (ePROs) among RA patients where they examine and record their own painful and/or swollen joints for DAS28 calculation and report their health assessment through Routine Assessment of Patient Index Data with 3 Measures (RAPID 3).MyRA Touch is an applications (App) that is user friendly and available in four major spoken languages (English, Chinese, Malay and Tamil) with an animated version for patients who are illiterate.

Objectives:

The objectives of this study are to determine the correlation between:

I)Patient-reported and physician reported DAS28 ESR/CRP

II)RAPID3 and Clinical Disease activity Index (CDAI)

III)RAPID3 and DAS28 ESR/CRP assessed by physician and patient

IV)RAPID3 and inflammatory markers ESR/CRP.

Methods:

This was a cross-sectional study carried out in the Rheumatology Unit of Hospital Tuanku Jaa’far. All data entered through MyRA Touch App from April 2018 till April 2020 was analysed.

Results:

There were a total of 562 patients who entered the data in the App, 87.9% were women. The ethnic compositions of the study subjects comprised of Indians (36.7%) followed by the Malays (34.7%),Chinese (26.3%) and other ethnics (2.3%). About half of patients (59.8%) were in the 51-70 age group whereas 22.9%,1.8% and 15.5% were in the 31-50,18-30 and above 70 age groups respectively. The majority of our patients (96%) were literate. A total of 54.3% of them received secondary education, 27% primary, 12.2% tertiary and 6.6% did not receive any formal education.

There was a high level of correlation between DAS28 ESR/CRP performed by patient and DAS28 ESR/CRP assessed by physician, (r=0.808 for DAS28 ESR and r=0.804 for DAS28 CRP). RAPID3 also showed high level of correlation with CDAI and DAS28 CRP assessed by patient (r=0.700 and r=0.718 respectively). There was a moderate correlation between DAS28 ESR/CRP done by physician with RAPID3 (r=0.656 and r=0.696 respectively).RAPID3 demonstrated little correlation with inflammatory markers ESR and CRP (r=0.141 and r=0.171 respectively).

Conclusion:

PROs via DAS 28 (ESR/CRP) and RAPID3 showed moderate to high correlation with disease activity assessed by physician. We can empower patients to perform their own disease assessment by using the MyRA Touch App before seeing their physician and the information provided in the App, can help to reduced consultation time. During the COVID-19 pandemic, telemedicine is very much encouraged. By using the MyRA Touch, patients can assess their own tender and swollen joint count on a homunculus, evaluate their own physical function, health and pain using the RAPID3 parameters. The information obtained from the PROs in the MyRA touch App enables the physician to make a more comprehensive virtual assessment of the patient’s condition which helps in treatment decision making. In conclusion, MyRA Touch is an useful tool for disease activity measurement by patient.

References:

[1]Jenny AA, Diana BC, Omar JC, et al. Usefulness of Patients-Reported Outcomes in Rheumatoid Arthritis Focus Group. Hindawi Publishing Corporation Arthritis, vol 2012,Article ID935187.

[2]Ana MO, Clifton OB. Patient Reported Outcomes in Rheumatoid Arthritis Clinical Trials. Curr Rheumato Rep.2015 April;17(4):501.

Disclosure of Interests:

None declared

The Application of ThyPRO Questionnaire in Patients With Graves’ Disease Treated With Antithyroid Medications

Background: The ThyPRO-39 questionnaire assesses health-related QoL (HRQoL) in patients with benign thyroid disease and has been validated for use in the local setting. The aim of the study is to investigate disease specific health-related quality of life using ThyPRO-39 in patients with newly diagnosed Graves’ disease treated with antithyroid medications over one year. Methods: Patients with newly diagnosed Graves’ disease were recruited in the outpatient setting. The ThyPRO-39 questionnaire was administered at baseline, 6 and 12 months of antithyroid medication treatment. Relevant demographic and clinical information was collected at the three time points of the study. Results of clinical parameters and various ThyPRO scales were compared between baseline, 6 months and 12 months of treatment. Results: There were 32 patients with newly diagnosed Graves’ disease recruited between April 2018 and May 2019. All except 2 patients completed all 3 time points of the study. Two patients missed their 6 months questionnaire. There were 24 females (75%) and 8 males (25%) in the study. Analysis of the clinical parameters showed significant changes in weight from baseline (59.7 + 17.7kg) to 6 months (59.4 + 9.9kg) to 12 months (63.4 + 17.4Kg), all p&lt;0.001, TSH receptor antibody level from baseline (17.3 + 12.9IU/L) to 12 months (7.1 + 10.8IU/L), NR &lt;1.76IU/L, p&lt;0.001, fT4 levels from baseline (49.9 + 18.1pmol/L) to 6 months (14.3 + 6.9pmol/L) and from baseline to 12 months (11.8 + 2.3pmol/L), NR 8.8-14.4pmol/L, all p&lt;0.001 and TSH levels from baseline (0.011 + 0.009mU/L) to 6 months (1.38 + 1.74mU/L, p=0.001) and from baseline to 12 months (1.80 + 1.72mU/L, p&lt;0.001), NR 0.65-3.70mU/L. After 6 months of treatment, 7 out of 13 ThyPRO scales improved and 9 out of 13 ThyPRO scales improved after 12 months of treatment. Large treatment effects were observed on 2 ThyPRO scales (Hyperthyroid symptoms and Anxiety) while moderate effects were seen in 5 ThyPRO scales (Tiredness, Cognitive complaints, Depressivity, Impaired daily Life and overall QoL) from baseline to 6 months. Large treatment effects were observed on 2 ThyPRO scales (Hyperthyroid symptoms and Anxiety) while moderate effects were seen in 5 ThyPRO scales (Tiredness, Depressivity, Emotional susceptibility, Impaired daily Life and overall QoL) from baseline to 12 months. Small treatment effects were observed in 2 ThyPRO scales (Goiter symptoms and Tiredness) from 6 to 12 months. Conclusion: There are significant improvements in many aspects HRQL during the first 6 months of antithyroid drug treatment, with hyperthyroid symptoms and anxiety showing the most improvements throughout the 12 month treatment period. Our results complement clinical monitoring of patients with Graves’ disease and provide realistic outcome measures of disease impact and treatment outcomes from the patient’s perspective.

Fluoroscopically assisted computer navigation enables accurate percutaneous screw placement for pelvic and acetabular fracture fixation

Percutaneous fixation of pelvic and acetabular fractures are technically demanding procedures, and high rates of screw misplacement and potential neurovascular complications have been reported. One hundred and sixty two screws from a prospectively collected database were analysed to evaluate the accuracy of a fluoroscopically assisted computer navigated technique to insert a cannulated screw to treat pelvic and acetabular fractures. Actual screw position and trajectory with the intraoperative surgical plan stored in the navigation computer. The actual screw position differed from the surgical plan by a mean of 3.9 mm, with a mean 1.4 degree difference in screw trajectory. Post operative CT analysis of patients showed 10 screws perforated cortical bone. Our results show that the use of computer navigation can aid in the accurate placement of percutaneous screws along a predefined plan. It is still possible to incorrectly place a screw and great care needs to be taken with the surgical plan and also to understand the complex anatomy of the bony pelvis.

Temperature preferences of male field crickets ( Gryllus integer) alter their mating calls

Temperature affects the mating displays of many ectothermic animals, yet almost no information exists on the temperature preferences of ectotherms while they are displaying for mates. This study investigated the preferences of displaying male field crickets ( Gryllus integer) for microhabitats of different temperatures. G. integer males attract sexually receptive females by calling from cracks in the ground. We collected data from the field on the temperature of male calling sites (cracks in the ground), on the amount of herbaceous cover (which affects crack temperature) surrounding calling sites, and on the temporal properties of male calls at different temperatures. Laboratory experiments demonstrated that males prefer warmer sites and confirmed that temperature influences mating calls. We conclude that males of this ectothermic species prefer to call for mates from warmer sites, and that microhabitat choice on the basis of temperature affects their mating calls, and potentially their reproductive success.

Systemic and microiontophoretic administration of morphine differentially effect ventral pallidum/substantia innominata neuronal activity

In vivo electrophysiological recording techniques were employed to examine responses of ventral pallidum/substantia innominata (VP/SI) neurons to systemic and local administration of morphine. Using a cumulative dosing protocol, intravenous administration (0.1-30 mg/kg i.v.) produced a suppression of firing in 82% of neurons tested. The suppression was dose-related and blocked by the opioid antagonist, naloxone. In contrast, microiontophoretic applications of morphine resulted in current-related suppression (32% of neurons tested) or excitation (26%). Concurrent application of naloxone attenuated or blocked both effects of local morphine application. It was demonstrated that acute tolerance did not develop with repeated morphine exposures following either systemic or local administration. The present findings establish the sensitivity of VP/SI neurons to morphine and provide functional relevance at the level of a single neuron for opioid peptides and their receptors in this region. As reported for most other opioid-receptive brain areas, neuronal rate suppression was the predominate response observed, and it is proposed that excitations to iontophoresed morphine reflect a disinhibitory phenomenon. The differential morphine-induced rate changes, and number of responding neurons, observed with systemic vs. iontophoretic morphine administration suggest that extra-VP/SI regions that also are opioid sensitive can subsequently direct neuronal responsiveness to opioids within the VP/SI.

The long-term effects of neurotoxic doses of methamphetamine on the extracellular concentration of dopamine measured with microdialysis in striatum

The extracellular concentrations of dopamine (DA), dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), and 5-hydroxyindoleacetic acid (5-HIAA) in the striatum were measured by in vivo microdialysis in freely moving rats one week after the animals were treated with neurotoxic doses of methamphetamine. Methamphetamine produced a marked depletion of striatal DA measured in postmortem tissue, and in the extracellular concentrations of DOPAC, HVA and 5-HIAA. In contrast, the resting extracellular concentration of DA in striatum was the same as in saline-pretreated controls. Furthermore, methamphetamine-pretreated rats were able to increase their concentration of extracellular DA to the same extent as controls in response to a (+)-amphetamine challenge. It is suggested that this adaptive response is probably responsible, at least in part, for the absence of obvious behavioral deficits in animals exposed to neurotoxic doses of methamphetamine.