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BACKGROUND Treatment of hyperglycemia with insulin is associated with increased risk of hypoglycemia in Type 2 Diabetes Mellitus (T2DM) patients receiving total parenteral nutrition (TPN). AIMS To determine the predictors of hypoglycemia in hospitalized T2DM patients receiving total parenteral nutrition (TPN). DESIGN Post-hoc analysis of the INSUPAR study, which is a prospective, open-label, multi-center, clinical trial on adult inpatients with Type 2 Diabetes in a non-critical setting with indication for TPN. RESULTS The study included 161 patients, 31 (19.3%) had hypoglycemic events, none of them was severe. In univariate analysis, hypoglycemia was significantly associated with the presence of diabetes with end-organ damage, duration of diabetes, use of insulin prior to the admission, glycemic variability (GV), belonging to the Glargine insulin group in the INSUPAR trial, mean daily g of lipids in TPN, mean insulin per 10 g of carbohydrates, duration of TPN and increase of urea during TPN. Multiple logistic regression analysis showed that the presence of diabetes with end-organ damage, GV, use of Glargine insulin and TPN duration were risk factors for hypoglycemia. CONCLUSION The presence of DM with end-organ damage complications, longer TPN duration, belonging to the Glargine insulin group and greater GV are factors associated with the risk of hypoglycemia in diabetic non-critically ill inpatients with parenteral nutrition.Objective To analyze the effects of methimazole (MMI)-containing combination regimens on the thyroid status and relapse rates in patients with Graves' hyperthyroidism (GH) using a network meta-analysis to provide guidance for clinical application. Methods We conducted a literature review which identified 21 trials for inclusion. The major outcomes were the serum free triiodothyronine (FT3) and free thyroxine (FT4) concentrations. The secondary outcome was the relapse rate. A network meta-analysis was used to compare multiple regimens to identify the most advantageous regimen. Results The types of combined drugs included antioxidant complexes, selenium, vitamin D3, cholestyramine, risedronate, iodine, potassium bromide, immunosuppressants, and β-adrenergic antagonists. Regarding the FT3 results, the rank probability of the best result showed that potassium bromide (0.897) and vitamin D3 (0.833) had relative advantages in reducing FT3 at the 1-month time point. According to the time trend analysis, compared with the control treatment, cholestyramine and iodine showed advantages in reducing FT3 during the early stage (0-3 month). The immunosuppressants showed advantages in reducing FT3 during the late stage (>9 month) but not the early stage. Regarding the FT4 results, potassium bromide had the highest p-score (0.965) at the 1-month time point. Iodine and cholestyramine had advantages in reducing FT4 during the early stage. The immunosuppressants had advantages during both the early and late stages. Conclusion MMI combined with cholestyramine or iodine was shown to regulate serum FT3 and FT4 during the early stage. MMI combined with immunosuppressants had a long-term advantage in FT3/FT4 regulation and reduced the relapse rate.Objective To investigate the long-term outcomes of radioiodine therapy (RIT) for juvenile Graves' disease (GD) and the ultrasonographic changes of the thyroid gland. Methods All of 117 juvenile patients (25 males and 92 females aged 10 to 18 [median 16] years) who had undergone RIT for GD at our clinic between 1999 and 2018 were retrospectively reviewed. Each RIT session was delivered on an outpatient basis. The maximum 131I dose per treatment was 13.0 mCi, and the total 131I dose per patient was 3.6-29.9 mCi (median 13.0 mCi). 131I administration was performed once in 89 patients, twice in 26, and thrice in 2. Ultrasonography of the thyroid gland was regularly performed after RIT. The duration of follow-up after the initial RIT ranged from 4 to 226 (median 95) months. Results At the latest follow-up more than 12 months after RIT (n=111), the patients' thyroid functions were overt hypothyroidism (91%), subclinical hypothyroidism (2%), normal (5%), or subclinical hyperthyroidism (2%). New thyroid nodules were detected in 9 patients, 4-17 years after initial RIT. Patients with newly detected thyroid nodules underwent RIT with lower doses of 131I, and had larger residual thyroid volumes than those without nodules. None of the patients were diagnosed with thyroid cancer or other malignancies during the follow-up period. Conclusion Over a median follow-up period of 95 months (range 4-226 months) RIT was found to be effective and safe in juvenile GD. However, cumulative evidence from further studies are required to confirm the long-term safety of RIT for juvenile GD.OBJECTIVES It is unclear whether the institution of gluten free diet (GFD) is beneficial in patients with type 1 diabetes (T1DM) and subclinical celiac disease (CD). PRIMARY OBJECTIVE To evaluate the effect of GFD on frequency of hypoglycemia, in patients with T1DM and subclinical CD. click here Secondary; effect of GFD on height, weight, glycosylated hemoglobin (HbA1c), insulin dose requirement and bone mineral homeostasis. METHODS Prospective open label randomized controlled trial (RCT). Patients with T1DM and subclinical CD were randomized to receive GFD or a normal diet for one year. Primary outcome was frequency of hypoglycemic episodes (blood glucose less then 70 mg/dl) measured by self-monitoring of blood glucose (SMBG) at 6th month in the two groups. RESULTS 320 T1DM patients were screened for CD. 30 eligible patients were randomized to receive GFD (n=15) or a normal diet (n=15). Mean number of hypoglycemic episodes/month recorded by SMBG and mean time spent in hypoglycemia measured by CGM (mins) in GFD group vs. non GFD group at 6th month was 2.3 vs 3.4 (p=0.5) and 124.1 vs 356.9 (p=0.1) respectively. Mean number of hypoglycemic episodes/month significantly declined in GFD group (3.5 at baseline vs. 2.3 at 6th month, p=0.03). Mean HbA1c declined by 0.73% in GFD group and rose by 0.99% in non GFD group, at study completion. CONCLUSION This is the first RCT to assess the effect of GFD in T1DM and subclinical CD. A trend towards decrease in hypoglycemic episodes and better glycemic control was seen in patients receiving GFD.Thyrotoxic periodic paralysis (TPP) is a muscular disorder characterized by sudden episodes of muscle weakness and hypokalemia in the setting of thyrotoxicosis. OBJECTIVE We aimed to report our experience with TPP in West Texas and compare its clinical presentation to that of patients admitted for complicated thyrotoxicosis. METHOD Retrospective review of records of adult patients with admission diagnosis of hyperthyroidism, thyrotoxicosis and/or discharge diagnosis of periodic paralysis seen at our institution in a six-year period. RESULTS Patients admitted for complicated thyrotoxicosis were more commonly females of a mean age of 44 years. Patients with TPP were more commonly Hispanic males of a mean age of 27 years. Despite no significantly different thyroid hormone levels, patients with TPP presented with less severe signs and symptoms of hyperthyroidism, as reflected by lower Burch Wartofsky score on admission (19 vs 35, p less then 0.001) and lower occurrence of atrial fibrillation in the TPP group (0% vs 36%, p less then 0.001). Finally 89% of TPP patients presented with QTc prolongation whereas only 19% of thyrotoxic patient presented with a prolonged QTc. CONCLUSION Hispanic patients with TTP seems to have relative resistance to the actions of thyroid hormones, and commonly present with QTc prolongation, a risk factor for cardiac arrhythmias.Objective. Diabetes mellitus (DM) is a risk factor for pancreatic cancer but its prognostic impact remains controversial. We aimed to investigate the association between long-standing DM and the risk of mortality. Methods. This population-based cohort study analyzed data from the national healthcare database in Taiwan. We identified all patients diagnosed with pancreatic cancer and excluded those who were diagnosed with DM within 2 years of the cancer diagnosis. Eligible patients were grouped into long-standing DM (>2 years) and non-diabetic controls, and were compared for overall survival using a Cox proportional hazard model. Sensitivity tests stratified by cancer stages (as indicated by specific treatment) were performed. Results. Patients with long-standing DM were significantly older (mean age, 71.38 vs. 66.0 years, P less then 0.0001) and had a higher Charlson comorbidity index (9.53 vs. 6.78, P less then 0.0001) and diabetes comorbidity severity index (2.38 vs. 0.82, P less then 0.0001) compared with the non-DM controls. Although the unadjusted analysis showed a higher risk of mortality in the patients with long-term DM (crude hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.20-1.33, P less then 0.0001), the association became insignificant after adjustment for age, sex, and comorbidity index (adjusted HR, 1.01; 95% CI, 0.95-1.06, P = 0.84). Subgroup analyses also showed no association between long-term DM and mortality in various subgroups stratified by cancer treatment. Conclusion. After adjusting for associated comorbidities and complications, long-standing DM per se was not an independent prognostic factor for overall survival in this nationwide population-based cohort with pancreatic cancer.Objective Software updatable insulin pumps, such as the tslim X2 pump from Tandem Diabetes Care, enable access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump, however little quantitative data exists on the software update process nor on pre/post therapeutic outcomes. We examined real-world usage and impact of a remote software updatable predictive low-glucose suspend (PLGS) technology designed to reduce hypoglycemic events in people with insulin-dependent diabetes. Methods Approximately 15,000 U.S. Tandem pump users remotely updated their tslim X2 software to Basal-IQ PLGS technology since its commercial release. We performed a retrospective analysis of users who uploaded at least 21 days of pre/post PLGS update usage data to the Tandem tconnect web application between August 28, 2018 and October 21, 2019 (n=6,170). Insulin delivery and sensor-glucose values were analyzed per recent international consensus and ADA guidelines. Software update performance was also assessed. Results Median software update time was 5.36 minutes. Overall glycemic outcomes for pre and post software update showed a decrease in sensor time less then 70 mg/dL from 2.14 to 1.18% (-1.01, 95% CI -0.97, -1.05, p less then 0.001), with overall sensor time 70-180 mg/dL increasing from 57.8 to 58.5% (0.64, 95% CI 0.04, 1.24, p less then 0.001). These improvements were sustained at 3, 6 and 9 months after the update. Conclusion Introduction of a software updatable PLGS algorithm for the Tandem tslim X2 insulin pump resulted in sustained reductions of hypoglycemia.Objective In a cohort of medullary thyroid cancer (MTC) patients with biochemical incomplete responses, 37-48% developed structural persistent disease; however, few indictors were available to distinguish those patients who were more likely to develop structural disease. We hypothesized that the relationship between preoperative calcitonin (Ctn) and postoperative Ctn (within 3 days after surgery) could be used to predict early prognosis of these patients. Methods A total of 92 sporadic MTC patients were enrolled in this study. Our team proposed a novel indicator of structural persistent MTC called the Calcitonin Ratio (CR, CR = postoperative Ctn / preoperative Ctn). Cox regression models and the Kaplan-Meier method were used to evaluate the prognostic capability of CR. The area under the time-dependent receiver-operating characteristic curves (AUC) and the Harrell concordance index (C-index) were used for analysis. Results The cutoff CR value used to determine MTC prognosis was 0.15. Multivariate Cox analysis revealed that CR (HR 22.