Glycemic Control and Awareness of Insulin Therapy.

INTRODUCTION: Glycemic control is associated with better health outcomes among patients with diabetes. No previous research has examined the relationship between knowledge of one's insulin dose and glycemic control. This study sought to determine if patients who accurately recalled their insulin dose achieved better glycemic control than patients who could not remember their dose. METHODS: Interviews were conducted with 106 patients. Data were collected during patients' appointments at two endocrinology clinics in Wichita, Kansas from May 29, 2018 to February 15, 2019. Adequate glycemic control was defined as an HbA1c of less than 7.5%. A multiple logistic regression model was developed to identify factors associated with glycemic control. RESULTS: Of the 109 patients asked to participate, 105 agreed to participate in the study. About half (45%, n = 48) were male. Patients' mean age was 50 years (SD = 17). Seventy-seven percent (n = 81) were overweight (body mass index (BMI) of 25 to 29.9) or obese (BMI >30). Patients who correctly stated their insulin dose had a mean Hemoglobin A1c (HbA1c) of 6.9% (SD = 0.98), whereas those who incorrectly stated their dose had a mean HbA1c of 9.5% (SD = 1.9; p <0.0001). CONCLUSIONS: There was a significant relationship between knowledge of one's insulin dose and adequate glycemic control.

Exceptional Regression of Malignant Pleural Mesothelioma with Pembrolizumab Monotherapy.

The lead author with clinical stage I malignant pleural mesothelioma, epithelioid type, highly programmed cell death ligand 1 (PD-L1) positive, and BAP1 negative, experienced a prompt and exceptionally favorable response to pembrolizumab monotherapy. After cessation of treatment due to immune-related endocrinopathies, complete metabolic response on interim PET/CT scan was achieved. Two years after initial diagnosis, unifocal tumor reactivation was addressed with successful pembrolizumab monotherapy rechallenge. Immunotherapy, typically not used as frontline treatment for malignant pleural mesothelioma, may provide an effective and durable response for some patients. Based on this single case study, epithelioid type tumors with strongly positive PD-L1 and BAP1-negative immunohistochemical markers may be well suited for treatment with immune checkpoint inhibitors such as pembrolizumab.

"Hyper-warburgism," a cause of asymptomatic hypoglycemia with lactic acidosis in a patient with non-Hodgkin's lymphoma.

CONTEXT: In cancer cells, the Warburg effect is defined as the avid consumption of glucose through the glycolytic pathway with concomitant lactate production, even under aerobic conditions. CASE: We report a 64-yr-old woman who was referred to our institution for pancytopenia and hypoglycemia. Physical examination demonstrated hepatosplenomegaly and petechiae. She had no clinical manifestation of neuroglycopenia, despite serum glucose of 26 mg/dl (1.4 mmol/liter) and serum lactate of 28.5 mmol/liter (normal range, 0.5-3.4 mmol/liter). Bone marrow biopsy demonstrated diffuse large B-cell lymphoma. Staging (18)F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography showed increased FDG avidity in an enlarged spleen and absent FDG uptake in the brain. Despite dextrose infusions up to 30 g/h, there was no increase in serum glucose, but there was a paradoxical increase in serum lactate. Immunochemotherapy improved the hematological and metabolic abnormalities. Follow-up FDG-positron emission tomography/computed tomography showed a decrease in splenic avidity and an increase in brain FDG avidity. The patient refused further chemotherapy and died 1 wk after discharge. METHODS: Literature review of cases of lymphoma with lactic acidosis, with and without hypoglycemia, demonstrated that these combinations occurred in multiple categories of B- and T-cell lymphoma. There was no difference in the mortality rate in those with (75%) or without (74%) concomitant hypoglycemia. CONCLUSION: This case represents an exaggerated Warburg effect, or "hyper-warburgism," characterized by excessive lactate production and overwhelming glucose consumption. We speculate that the decreased brain FDG uptake, despite the lack of neuroglycopenic symptoms, supports the hypothesis that lactate served as a fuel for the brain, thus protecting against hypoglycemia.