- Email: [email protected]
Hypoglycemia Due to Large Insulinoma in a Patient with Prostate Adenocarcinoma
Abstracts / Can J Diabetes 41 (2017) S22–S83
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Methods: A retrospective chart review was performed on patients attending an adult TS clinic jointly run by gynecology and endocrinology at a university-based ambulatory hospital. All patients had a diagnosis of TS based on karyotype testing and attended clinic at least once between 2012–2015. Charts were reviewed for evidence of chronic medical conditions. Results: There were 82 women with TS identified. The mean age was 38.4 years (range 21–71 years) and 42.7% were older than 40 years. At least one chronic medical condition was present in 79% of our cohort. Twenty-nine women (35.4%) had hypothyroidism, 26 (31.7%) had osteopenia or osteoporosis, 15 (18.9%) had hypertension, 10 (12.2%) had pre-diabetes or diabetes and 5 (6.1%) had celiac disease. With regards to cardiovascular complications, 34 (41.4%) women had valvular or aortic abnormalities and 5 (6.1%) had a history of coronary artery disease or congestive heart failure. Conclusions: We report a high prevalence of endocrine and cardiovascular conditions in an older cohort of women with TS. This cohort is unique given the older age of our patients as well as the high burden of comorbid disease that we identified. Our findings underscore the need for ongoing, multi-disciplinary care for older women with TS.
ghrelin levels. Importantly L-cysteine is an amino acid which is metabolized into H2S by cells containing the enzyme cystathionine gamma-lyase (CSE), and preliminary data suggests the stomach is enriched with CSE. Once produced, H2S plays a variety of regulatory roles in the cardiovascular, immune, and metabolic endocrine systems. Research Question: Does H2S production within the stomach lead to the suppression of ghrelin secretion, and does this occur through the conversion of L-cysteine by CSE? Methods and Results: To investigate the direct effect of H2S on ghrelin secretion, primary rat stomach cells were examined. Treatment with H2S donors (NaHS and GYY4137) led to a significant suppression in ghrelin secretion. Similar results were found when cells were treated with L-cysteine. The importance of L-cysteine to H2S conversion was confirmed by co-incubating treatments with inhibitors of CSE. Ongoing work in mice will determined the impact of H2S on ghrelin-induced appetite suppression Implications: This study will determine whether gasotransmitters like endogenous H2S could affect the regulation of appetite and energy metabolism, and provide a possible mechanism for high protein meals (l-cysteine) in enhanced satiety.
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Triage Consult Management: An Educational Intervention for Endocrinology Subspecialty Residents MAHUA GHOSH, PETER A. SENIOR Edmonton, AB
Patient and Provider Experience with MyChart™ Access in Endocrinology and Metabolism Clinics JILL TRINACTY*, ERIN KEELY, MARY-ANNE DOYLE, SILVANA SEDRA Ottawa, ON Patient portals into electronic medical records have been developed to improve patient access to medical information. The Ottawa Hospital (TOH) chose to use MyChart™ which includes laboratory, pathology, imaging results and clinic notes. We aimed to capture the experience at TOH for both patients and providers. Patients who attended the Endocrinology/Metabolism Clinic between October 12 and October 25, 2016 were eligible to participate. Patient interest was evaluated by determining the number of patients per clinic who provided an email contact and access data was extracted from MyChart™ records. All patients who consented were sent a 37 item survey by email 2 weeks after the pilot closed. Health care providers (MDs, RNs, RDs) received a survey prior to the pilot period to determine their perceptions. Of 641 patients, 191 (29.8%) provided an email address and 59 (9.2%) created a user profile. These users accessed the portal 395 times, an average of 6.7 times per patient. Laboratory results were the most viewed. Those accessing felt they better understood their health and medical conditions (88.2%) and only 4% reported worrying more. Twenty-five providers responded to the pre-pilot survey. All felt patient satisfaction would improve. Almost half (40%) of providers reported that they were moderately or very concerned that they would be less candid in their documentation. The MyChart™ portal was anticipated positively by providers and viewed favourably by patients. Using an online portal to enhance access can improve patients understanding of their medical conditions, increase patient engagement in their care and encourage provider-patient communication.
Background: The purpose of triage in Endocrinology office is to ensure that patients receive appropriate care timely. Important consultation skills are required to triage effectively and safely to offer timely clinic consult, telephone advice and even denial of the consult request. Triage is a required skill for a competent endocrinologist; however, it is not a structured component of training for Endocrinology Subspecialty Residents. Aim: The aim for this project is to evaluate the effectiveness of triage consult as an educational intervention for Endocrinology residents. Method: We used the six steps of the framework for Curriculum Development. With the lack of literature, the problem identification and targeted needs assessment, was completed during the Residency Program Committee meetings. We agreed on the objective that residents would review all 30 to 40 triage consults that come to the division of Endocrinology for at least 3 days and discuss with the preceptor at the end of the day for management plan. We collected feedback from recent graduates and current residents. Result: Out of 10 recent graduates, 8 replied to the evaluations. All agreed that the triage consult offered an unique educational opportunity for both medial expert and non-medical expert roles. Conclusion: The feedback was discussed in the RPC meeting and all agreed in favor of increasing triage days to 10 days during their 2 years training. We have successfully implemented supervised triage consult as educational intervention for senior subspecialty residents during transition to practice. 85 The Role of Hydrogen Sulfide (H2S) in Ghrelin Secretion ERIK SLADE, LAURA WILLIAMS, JEFFREY GAGNON Sudbury, ON Background: Ghrelin is a stomach derived hormone that stimulates appetite, regulates energy storage and stimulates gastric motility. Ghrelin levels are highest before meal times and are suppressed immediately after food consumption, with the longest suppression occurring after high protein meals. Prior studies show that consumption of the amino acid L-cysteine in rats and humans decreases
87 Hypoglycemia Due to Large Insulinoma in a Patient with Prostate Adenocarcinoma SHIVRAJ RIAR*, JEREMY FITZGERALD Regina, SK Hypoglycemia is a common yet confounding clinical condition in which an organized yet concise clinical approach can help guide
S32
Abstracts / Can J Diabetes 41 (2017) S22–S83
appropriate biochemical and radiological testing especially in complicated rare cases. A 65-year-old non-Diabetic male, with a recent diagnosis of Prostate Adenocarcinoma, presented with increasing appetite, fatigue and drowsiness. Given investigations, which revealed fasting plasma glucose of 2.2 mmol/L, an urgent referral was sent to Endocrinology. The patient met criteria for Whipple’s triad and further testing revealed elevated serum Insulin 599 pmol/L, and C-Peptide 2403 pmol/L. Insulin Antibodies were negative; IGF-1 and Chromogranin A levels were elevated at 212 ug/L and 236 ng/mL respectively. Given the strong clinical and biochemical suspicion for a neuroendocrine tumor, an MRI of the pancreas was performed (Image-1) and identified a large, 3.5 cm lesion in the tail of the pancreas consistent with an Insulinoma. The patient underwent a distal pancreatectomy and splenectomy, as the growth had invaded into the spleen, with the pathology report confirming findings consistent with an Insulinoma. This case illustrates very unique features; firstly it showcases the diagnosis of Insulinoma in the unusual context of Prostate Adenocarcinoma, as there are no such reported cases in the literature. Secondly, the size of this Insulinoma is unusually large with the majority of these lesions measuring less than 2 cm. Apart from its unique features; the case highlights the utility of a step-by-step approach to hypoglycemia in reaching a final diagnosis in rare clinical scenarios.
Figure 1. Insulin-induced hypoglycemia stimulation test.
hypoglycemia stimulation testing revealed inadequate cortisol response. The remainder of the endocrine work-up was unremarkable, and magnetic resonance imaging revealed no pituitary or adrenal lesions. Clinical outcome: The patient was diagnosed with secondary/ tertiary adrenal insufficiency of unclear etiology, in association with NS. Her syncopal episodes and hypotension resolved following treatment with hydrocortisone. Discussion: NS is estimated to have a prevalence of approximately 1 in 1000–2500. This autosomal dominant disorder is characterized by pulmonary valve stenosis among other cardiac abnormalities, café au lait spots, coagulation defects, lymphatic abnormalities, skeletal malformations, ptosis, and hypertelorism. Growth hormone secretion abnormalities are often found in children with NS. However, no other pituitary hormone secretion abnormalities have been strongly associated to NS. Only one case of hypopituitarism with growth hormone, gonadotropin and thyroid stimulating hormone deficiency associated with NS was reported by Ross and Shenkman in 1980. Conclusion: The case described above is the first reported case of adrenal insufficiency associated to NS.
89 Vitamin D directly inhibits TRPV1 channels and reduces the activation of naïve T-cells WENTONG LONG, MOHAMMAD FATEHI, AMY BARR, REES KELLY, MORGANNE HELD, YI YUTROY BALDWIN, PETER LIGHT Edmonton, AB
88 A Case of Adrenal Insufficiency Associated with Noonan’s Syndrome MICHAEL TSOUKAS*, AURELIE PARE Montreal, QC Clinical presentation: An 18 year-old female known for Noonan’s syndrome (NS) presented to the emergency room for recurrent syncope. She also had complaints of progressive fatigue and generalized weakness, and was found to be hypotensive on arrival. Morning cortisol was <11 nmol/L. Adrenocorticotropic hormone was inappropriately within the normal range. Insulin-induced
Recent evidence suggests that Vitamin D plays an important role in regulating immune T-cell activity and may be involved in reducing the risk of Type 1 Diabetes (T1D) by dampening naïve T-cell activation and/or the inflammatory response. However, the exact mechanism of how Vitamin D modulates the activation of naïve T-cells is still unknown. It is generally thought that Vitamin D acts almost exclusively on the Vitamin D receptor (VDR). However, the very low or absent VDR expression levels in naïve T-cells suggest any effects of Vitamin D on naïve T-cell activation may be VDRindependent. In this regard, it has ben shown that TRPV1 channels activation is necessary for naïve CD4+ T-cell activation. Interestingly, our electrophysiological data demonstrate that both the inactive circulating 25OHD and the active 1,25OHD are inhibitors of TRPV1 channels at physiologically relevant concentrations. Therefore, we hypothesized that 25OHD and 1,25OHD may modulate naïve T-cell activation through direct inhibition of TRPV1 channels. In this study, we characterized the effects of 25OHD and 1,25OHD on 1) TRPV1 channels and 2) the activation and cytokine production of naïve mouse T-cell through flow cytometry analysis. We found that 25OHD and 1,25OHD are effective inhibitors of TRPV1 channels in the 50–200 nM physiological range and this effect is dependent on intracellular calcium levels. Our results also
S31
Methods: A retrospective chart review was performed on patients attending an adult TS clinic jointly run by gynecology and endocrinology at a university-based ambulatory hospital. All patients had a diagnosis of TS based on karyotype testing and attended clinic at least once between 2012–2015. Charts were reviewed for evidence of chronic medical conditions. Results: There were 82 women with TS identified. The mean age was 38.4 years (range 21–71 years) and 42.7% were older than 40 years. At least one chronic medical condition was present in 79% of our cohort. Twenty-nine women (35.4%) had hypothyroidism, 26 (31.7%) had osteopenia or osteoporosis, 15 (18.9%) had hypertension, 10 (12.2%) had pre-diabetes or diabetes and 5 (6.1%) had celiac disease. With regards to cardiovascular complications, 34 (41.4%) women had valvular or aortic abnormalities and 5 (6.1%) had a history of coronary artery disease or congestive heart failure. Conclusions: We report a high prevalence of endocrine and cardiovascular conditions in an older cohort of women with TS. This cohort is unique given the older age of our patients as well as the high burden of comorbid disease that we identified. Our findings underscore the need for ongoing, multi-disciplinary care for older women with TS.
ghrelin levels. Importantly L-cysteine is an amino acid which is metabolized into H2S by cells containing the enzyme cystathionine gamma-lyase (CSE), and preliminary data suggests the stomach is enriched with CSE. Once produced, H2S plays a variety of regulatory roles in the cardiovascular, immune, and metabolic endocrine systems. Research Question: Does H2S production within the stomach lead to the suppression of ghrelin secretion, and does this occur through the conversion of L-cysteine by CSE? Methods and Results: To investigate the direct effect of H2S on ghrelin secretion, primary rat stomach cells were examined. Treatment with H2S donors (NaHS and GYY4137) led to a significant suppression in ghrelin secretion. Similar results were found when cells were treated with L-cysteine. The importance of L-cysteine to H2S conversion was confirmed by co-incubating treatments with inhibitors of CSE. Ongoing work in mice will determined the impact of H2S on ghrelin-induced appetite suppression Implications: This study will determine whether gasotransmitters like endogenous H2S could affect the regulation of appetite and energy metabolism, and provide a possible mechanism for high protein meals (l-cysteine) in enhanced satiety.
84
86
Triage Consult Management: An Educational Intervention for Endocrinology Subspecialty Residents MAHUA GHOSH, PETER A. SENIOR Edmonton, AB
Patient and Provider Experience with MyChart™ Access in Endocrinology and Metabolism Clinics JILL TRINACTY*, ERIN KEELY, MARY-ANNE DOYLE, SILVANA SEDRA Ottawa, ON Patient portals into electronic medical records have been developed to improve patient access to medical information. The Ottawa Hospital (TOH) chose to use MyChart™ which includes laboratory, pathology, imaging results and clinic notes. We aimed to capture the experience at TOH for both patients and providers. Patients who attended the Endocrinology/Metabolism Clinic between October 12 and October 25, 2016 were eligible to participate. Patient interest was evaluated by determining the number of patients per clinic who provided an email contact and access data was extracted from MyChart™ records. All patients who consented were sent a 37 item survey by email 2 weeks after the pilot closed. Health care providers (MDs, RNs, RDs) received a survey prior to the pilot period to determine their perceptions. Of 641 patients, 191 (29.8%) provided an email address and 59 (9.2%) created a user profile. These users accessed the portal 395 times, an average of 6.7 times per patient. Laboratory results were the most viewed. Those accessing felt they better understood their health and medical conditions (88.2%) and only 4% reported worrying more. Twenty-five providers responded to the pre-pilot survey. All felt patient satisfaction would improve. Almost half (40%) of providers reported that they were moderately or very concerned that they would be less candid in their documentation. The MyChart™ portal was anticipated positively by providers and viewed favourably by patients. Using an online portal to enhance access can improve patients understanding of their medical conditions, increase patient engagement in their care and encourage provider-patient communication.
Background: The purpose of triage in Endocrinology office is to ensure that patients receive appropriate care timely. Important consultation skills are required to triage effectively and safely to offer timely clinic consult, telephone advice and even denial of the consult request. Triage is a required skill for a competent endocrinologist; however, it is not a structured component of training for Endocrinology Subspecialty Residents. Aim: The aim for this project is to evaluate the effectiveness of triage consult as an educational intervention for Endocrinology residents. Method: We used the six steps of the framework for Curriculum Development. With the lack of literature, the problem identification and targeted needs assessment, was completed during the Residency Program Committee meetings. We agreed on the objective that residents would review all 30 to 40 triage consults that come to the division of Endocrinology for at least 3 days and discuss with the preceptor at the end of the day for management plan. We collected feedback from recent graduates and current residents. Result: Out of 10 recent graduates, 8 replied to the evaluations. All agreed that the triage consult offered an unique educational opportunity for both medial expert and non-medical expert roles. Conclusion: The feedback was discussed in the RPC meeting and all agreed in favor of increasing triage days to 10 days during their 2 years training. We have successfully implemented supervised triage consult as educational intervention for senior subspecialty residents during transition to practice. 85 The Role of Hydrogen Sulfide (H2S) in Ghrelin Secretion ERIK SLADE, LAURA WILLIAMS, JEFFREY GAGNON Sudbury, ON Background: Ghrelin is a stomach derived hormone that stimulates appetite, regulates energy storage and stimulates gastric motility. Ghrelin levels are highest before meal times and are suppressed immediately after food consumption, with the longest suppression occurring after high protein meals. Prior studies show that consumption of the amino acid L-cysteine in rats and humans decreases
87 Hypoglycemia Due to Large Insulinoma in a Patient with Prostate Adenocarcinoma SHIVRAJ RIAR*, JEREMY FITZGERALD Regina, SK Hypoglycemia is a common yet confounding clinical condition in which an organized yet concise clinical approach can help guide
S32
Abstracts / Can J Diabetes 41 (2017) S22–S83
appropriate biochemical and radiological testing especially in complicated rare cases. A 65-year-old non-Diabetic male, with a recent diagnosis of Prostate Adenocarcinoma, presented with increasing appetite, fatigue and drowsiness. Given investigations, which revealed fasting plasma glucose of 2.2 mmol/L, an urgent referral was sent to Endocrinology. The patient met criteria for Whipple’s triad and further testing revealed elevated serum Insulin 599 pmol/L, and C-Peptide 2403 pmol/L. Insulin Antibodies were negative; IGF-1 and Chromogranin A levels were elevated at 212 ug/L and 236 ng/mL respectively. Given the strong clinical and biochemical suspicion for a neuroendocrine tumor, an MRI of the pancreas was performed (Image-1) and identified a large, 3.5 cm lesion in the tail of the pancreas consistent with an Insulinoma. The patient underwent a distal pancreatectomy and splenectomy, as the growth had invaded into the spleen, with the pathology report confirming findings consistent with an Insulinoma. This case illustrates very unique features; firstly it showcases the diagnosis of Insulinoma in the unusual context of Prostate Adenocarcinoma, as there are no such reported cases in the literature. Secondly, the size of this Insulinoma is unusually large with the majority of these lesions measuring less than 2 cm. Apart from its unique features; the case highlights the utility of a step-by-step approach to hypoglycemia in reaching a final diagnosis in rare clinical scenarios.
Figure 1. Insulin-induced hypoglycemia stimulation test.
hypoglycemia stimulation testing revealed inadequate cortisol response. The remainder of the endocrine work-up was unremarkable, and magnetic resonance imaging revealed no pituitary or adrenal lesions. Clinical outcome: The patient was diagnosed with secondary/ tertiary adrenal insufficiency of unclear etiology, in association with NS. Her syncopal episodes and hypotension resolved following treatment with hydrocortisone. Discussion: NS is estimated to have a prevalence of approximately 1 in 1000–2500. This autosomal dominant disorder is characterized by pulmonary valve stenosis among other cardiac abnormalities, café au lait spots, coagulation defects, lymphatic abnormalities, skeletal malformations, ptosis, and hypertelorism. Growth hormone secretion abnormalities are often found in children with NS. However, no other pituitary hormone secretion abnormalities have been strongly associated to NS. Only one case of hypopituitarism with growth hormone, gonadotropin and thyroid stimulating hormone deficiency associated with NS was reported by Ross and Shenkman in 1980. Conclusion: The case described above is the first reported case of adrenal insufficiency associated to NS.
89 Vitamin D directly inhibits TRPV1 channels and reduces the activation of naïve T-cells WENTONG LONG, MOHAMMAD FATEHI, AMY BARR, REES KELLY, MORGANNE HELD, YI YUTROY BALDWIN, PETER LIGHT Edmonton, AB
88 A Case of Adrenal Insufficiency Associated with Noonan’s Syndrome MICHAEL TSOUKAS*, AURELIE PARE Montreal, QC Clinical presentation: An 18 year-old female known for Noonan’s syndrome (NS) presented to the emergency room for recurrent syncope. She also had complaints of progressive fatigue and generalized weakness, and was found to be hypotensive on arrival. Morning cortisol was <11 nmol/L. Adrenocorticotropic hormone was inappropriately within the normal range. Insulin-induced
Recent evidence suggests that Vitamin D plays an important role in regulating immune T-cell activity and may be involved in reducing the risk of Type 1 Diabetes (T1D) by dampening naïve T-cell activation and/or the inflammatory response. However, the exact mechanism of how Vitamin D modulates the activation of naïve T-cells is still unknown. It is generally thought that Vitamin D acts almost exclusively on the Vitamin D receptor (VDR). However, the very low or absent VDR expression levels in naïve T-cells suggest any effects of Vitamin D on naïve T-cell activation may be VDRindependent. In this regard, it has ben shown that TRPV1 channels activation is necessary for naïve CD4+ T-cell activation. Interestingly, our electrophysiological data demonstrate that both the inactive circulating 25OHD and the active 1,25OHD are inhibitors of TRPV1 channels at physiologically relevant concentrations. Therefore, we hypothesized that 25OHD and 1,25OHD may modulate naïve T-cell activation through direct inhibition of TRPV1 channels. In this study, we characterized the effects of 25OHD and 1,25OHD on 1) TRPV1 channels and 2) the activation and cytokine production of naïve mouse T-cell through flow cytometry analysis. We found that 25OHD and 1,25OHD are effective inhibitors of TRPV1 channels in the 50–200 nM physiological range and this effect is dependent on intracellular calcium levels. Our results also