Background American Diabetes Association (ADA) sets annual guidelines on preventative measures that aim to delay the onset of severe diabetes mellitus complications. Compared to private internal medicine clinics, resident clinics provide suboptimal diabetic preventative care as evidenced by decreased compliance with ADA guidelines. The purpose of our study is to improve diabetic care in resident clinics through quality improvement (QI) projects, with A1C value as primary outcome and other ADA guidelines as secondary outcomes. Methods Our resident clinic at Beaumont Hospital, Royal Oak consists of 76 residents divided in 8 teams. In November 2016, baseline data on ADA guideline measures was obtained on 538 patients with diabetes mellitus. A root cause analysis was conducted. 5 teams developed a QI intervention plan to improve their diabetes care and 3 teams served as comparisons without intervention plans. In November 2017, post-intervention data was collected. Results Baseline characteristics demonstrate mean age of intervention groups at 60.9 years and of comparison groups at 58.9 years. The change in A1C value from baseline to post-intervention was + 0.09 vs. + 0.322 in the intervention and comparison groups respectively ( p = 0.174). As a group, the changes in secondary outcome measures were as follows: eye examinations (+ 5% in intervention vs. -7% in comparison, p < 0.01), foot examinations (+ 13% vs. + 5%, p = 0.09), lipid panel testing (+ 7% vs. -5%, p < 0.01), micro-albumin/creatinine ratio testing (+ 4% vs. + 1%, p = 0.03), and A1C testing (+8% vs. + 5%, p = 0.24). Conclusions While the QI project did not improve A1C value, it did have significant improvement in several secondary outcomes within intervention groups. One resident team implemented an intervention involving protected half-day blocks to identify overdue examinations and consequently had the largest improvements, thus serving as a potential intervention to further study. Given our study results, we believe that QI interventions improve preventative care for patients with diabetes in resident clinics. Electronic supplementary material The online version of this article (10.1186/s40842-019-0084-9) contains supplementary material, which is available to authorized users.

Background Gastric bypass (GB) and sleeve gastrectomy (SG) remain the most effective intervention for weight loss in obesity. Our previous data showed a significant effect of preexisting diabetes on weight loss over 5 years. Since nonalcoholic fatty liver disease (NAFLD) is implicated as a precursor to clinical diabetes in obesity, we sought to determine if preexisting NAFLD modified weight loss outcomes. Methods 714 patients [79. 0% females, median age: 45 (37-53)] undergoing bariatric surgery were followed for 5 years. Clinically significant NAFLD at baseline was defined with a composite definition, combining the presence diagnosis on the medical record, definitive evidence for fat on imaging studies, presence of biopsy proving NAFLD, and/or elevation of liver function tests without another explanation. To screen for the presence of NAFLD, a natural language-processing tool EMERSE was utilized, and results were verified manually. Presence of diabetes, hypertension, and dyslipidemia were also defined using a combination of diagnostic codes, natural language processing and manual verification. Weight loss was tracked during annual visits and calculated using baseline weight and BMI. Total percent weight loss from baseline (%TWL) was also calculated. Results Of the 714 patients, 380 underwent GB [80.3% females, age 45 (35-53), median BMI 46.4 (41.6-51.9)] and 334 underwent SG [77.5% females, age 46 (39-54), BMI 49.7 (43.7-54.1)]. Overall, 31. 0% patients had clinically significant NAFLD at baseline, while the prevalence of diabetes, hypertension and dyslipidemia were 36. 0%, 54.9%, and 29.4% respectively. %TWL was impacted significantly by NAFLD in the GB group, as individuals without NAFLD lost medians of32.30 (26. 07-37.35), 32.33 (25. 04-39.21),31.12 (21.89-37.64), 26.40 (19.96-36.20), and 25.86 (18.16-34.79)%TWL versus29.63 (24.14-35.28),27.88 (21.44-35.11),24.15 (18.80-34.42),22. 09 (17. 03-30. 07), and21. 06 (14.92-30.25)%TWL compared to those with NAFLD by years1, 2, 3, 4, and 5 (p=0. 014,0. 002,0. 001,0. 002, and 0. 008). Among the SG group, differences in %TWL in NAFLD and non-NAFLD groupswere also significant, but only during year 1 and 2; non-NAFLD group had medians of25.73 (21.36-31.97) and24.55 (18.35-31.24) %TWL vs,22.48 (17.10-27.63) and22.28 (14.75-28.31)%TWL in NAFLD-group (p=&lt;0. 001 and 0. 02). In a multivariable model for %TWL, preexisting NAFLD remained a highly significant covariate when adjusted for baseline BMI, age, gender, surgery type, time (year of follow up), time by surgery type, preexisting diabetes, baseline cholesterol and triglyceride levels (Beta; 95% CI: - 2.288; -3.938, -0.639 p=0. 0067). Of note, the only other significant covariate with regards to comorbidities was presence of baseline diabetes (Beta; 95% CI: -2.811; -4.602, -1. 021, p=0. 0022). Conclusions Preexisting NAFLD impacts weight loss outcomes in patients undergoing bariatric surgery, more so in GB than SG. Mechanisms for the role of clinically significant NAFLD or diabetes in reducing weight loss potential after bariatric surgery require further studies. Presentation: No date and time listed

There have been conflicting results regarding the effect of proton pump inhibitors (PPIs) as an adjunctive therapy to oral antidiabetic medication (OAM) in those with type 2 diabetes (T2DM). PPIs increase gastrin levels, causing a rise in insulin. No studies have evaluated the duration of PPI therapy and its effect on glycemic control. Medical records across 8 hospitals between 2007 and 2016 were reviewed for 14,602 patients with T2DM (not on insulin therapy) taking PPIs. Values of HbA1c (baseline, follow-up, and the difference between the two) in those prescribed with PPIs and years of therapy were compared to HbA1c values of those who had no record of PPI use. Baseline and follow-up HbA1c for patients on PPIs were 6.8 and 7.0, respectively, compared to 7.1 and 7.2 in their untreated counterparts ( p < 0.001 in both comparisons). For both groups, an increase in baseline HbA1c was seen with time. Those on PPI had an increase in HbA1c of 0.16 compared to 0.08 in those not prescribed PPI. Our results show no relationship between the length of PPI therapy and HbA1c reduction.

Rationale: Familial hypocalciuric hypercalcemia (FHH) is a benign cause of hypercalcemia. The majority of cases result from an inactivating mutation in the calcium-sensing receptor (CaSR). While affected patients are usually asymptomatic and require no treatment, this condition may go unrecognized and inappropriate parathyroidectomy for presumed primary hyperparathyroidism could be performed. Over 130 mutations in the CaSR gene have been reported and novel variants continue to emerge. Methods: The initial patient was a 49 year-old female who presented with mild hypercalcemia, elevated PTH and undetectable urine calcium. She reported several of her family members had elevated calcium levels. Given high clinical suspicion for FHH genetic analysis was performed. Results: Sequencing of the CaSR gene revealed a point mutation at c.1744T&gt;A which resulted in p.Cys582Ser in exon 7. This cystine residue is highly conserved and predictive algorithms suggest this variant is likely disruptive leading to heterozygous loss of function in the CaSR. The patient’s 26 year-old daughter was tested and found to have the same mutation. Conclusion: We report the identification of a novel heterozygous mutation in the CaSR gene manifesting as FHH in a family of Iraqi decent. Additional family members are currently undergoing genetic analysis which will be included at the time of presentation.

Background Aneurysms of the internal carotid arteries are a rare cause of pituitary dysfunction1. While there are reports of primary amenorrhea in females due to ectatic internal carotid arteries2, hypogonadism in a male due to "kissing internal carotid arteries" causing compression of the pituitary gland has not previously been reported. Clinical Case A 27-year-old male with history of Crohn's disease, obesity, depression and sleep apnea on CPAP presented to endocrinology clinic for evaluation of low testosterone levels diagnosed 9 months prior to his initial visit. At the time of initial evaluation patient was using intramuscular testosterone cypionate 120mg weekly with total testosterone of 2.43 ng/mL (2.50-9.50 ng/mL). Testosterone replacement therapy was discontinued at that time to assess the hypothalamic-pituitary-gonadal (HPG) axis. After 9 months without testosterone treatment, repeat labs demonstrated total testosterone 0.91 ng/mL, bioavailable testosterone 0.69 ng/mL (1.10-4.0 ng/mL), SHBG 8 nmol/L (10-89 nmol/L), LH 3.1 mIU/mL (2-12 mIU/mL), FSH 2.7 mIU/mL (1.5-10 mIU/mL), estradiol 23 pg/mL (6-44 pg/mL), IGF-1 193 ng/mL (85-310 ng/mL), prolactin 10 ng/mL (3-23 ng/mL), TSH 1.03 mIU/L (0.3-5.5 mIU/L), FT4 1.15 ng/dL (0.76-1.70 ng/dL), 8 AM cortisol 13.5 ug/dL (5.3-22.5 ug/dL) and ACTH 37 pg/mL (5-52 pg/mL). Semen analysis was also performed which was unremarkable. Pituitary MRI revealed symmetric ectatic cavernous portions of the internal carotid arteries compressing and distorting the normal anatomy of the anterior pituitary gland consistent with "kissing carotid arteries." MRA was performed which did not demonstrate aneurysm or malformation of the cavernous internal carotid arteries. Patient was started on subcutaneous semaglutide 0.25mg weekly which was titrated to 1mg weekly for treatment of obesity. Testosterone replacement therapy was not re-initiated given future fertility goals and normal semen analysis. Conclusion To our knowledge, this is the first reported case of kissing internal carotid arteries causing isolated hypogonadotropic hypogonadism in a male patient. References 1) Heshmati HM, Fatourechi V, Dagam SA, Piepgras DG. Hypopituitarism caused by intrasellar aneurysms. Mayo Clin Proc. 2001 Aug;76(8): 789-93. doi: 10.1016/S0025-6196(11)63222-9. PMID: 11499817 2) Sahin M, Dilli A, Karbek B, Unsal IO, Gungunes A, Colak N, Uçan B, Cakal E, Ozbek M, Delibasi T. Unusual cause of primary amenorrhea due to kissing internal carotid arteries. Pituitary. 2012 Jun;15(2): 258-9. doi: 10.1007/s11102-012-0393-9. PMID: 22492265. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:44 p.m. - 12:49 p.m.