Euglycemic diabetic ketoacidosis in a patient with new-onset type 1 diabetes following a ketogenic diet: a potential risk of a dangerous dietary trend.

Euglycemic diabetic ketoacidosis (DKA) is a rare complication of diabetes mellitus (DM) characterized by metabolic acidosis, ketosis, and blood glucose levels < 250 mg/dL. The prevalence of euglycemic DKA is increasing with the popularity of ketogenic (low-carbohydrate) diets. We present herein the case of a patient with newly diagnosed type 1 DM who developed euglycemic DKA following a ketogenic diet. A 22-year-old woman presented to the emergency department with malaise, fatigue, nausea, and vomiting. She had no family history of DM. She had consulted her primary care physician 2 weeks before due to hair loss, numbness, and tingling sensation in her fingertips. Her fasting blood glucose was 205 mg/dL at that time. Reluctant to use medication to control her blood glucose levels, she started a ketogenic diet. On admission, she was conscious, oriented, cooperative, and tachycardic. Her body mass index was 17.6 kg/m2. Laboratory tests showed fasting blood glucose of 86 mg/dL, glycated hemoglobin of 10.3%, and elevated insulin levels. Ketone levels in urine and blood were high, indicating ketosis. High anion-gap metabolic acidosis was detected, with a pH of 7.10 and serum bicarbonate level of 12 mEq/L. A diagnosis of new-onset DM and euglycemic DKA was established. She was treated with a modified DKA protocol that included intravenous dextrose-containing serum as fluid therapy, and intravenous insulin infusion was delayed until blood glucose levels increased above 250 mg/dL. The development of euglycemic DKA in our patient was attributed to severe carbohydrate restriction. This case underscores the importance of considering dietary risk factors, particularly ketogenic diets, in the management of DM.

Assessing the accuracy and reliability of ChatGPT's medical responses about thyroid cancer.

PURPOSE: ChatGPT has the potential to offer patient-friendly support. Thyroid carcinoma has become increasingly prevalent in recent years. This study aimed to assess ChatGPT's accuracy and adequacy in answering questions about information, management, and emotional support related to thyroid cancer. METHODS: We conducted a three-step study. In the first step, ChatGPT responded to 30 questions about thyroid cancer. In the second step, we presented three different cases of thyroid cancer patients and asked ChatGPT about their diagnosis, treatment management, and follow-up. In the third step, we inquired about emotional support for patients and their families. Three expert endocrinologists graded these responses according to ATA guidelines. RESULTS: We showed that ChatGPT regurgitated extensive knowledge of thyroid cancer (76.66% correct), but only small proportions (6.66%) were labeled as mixed with correct and incorrect/outdated data. However, it was inadequate in the evaluation of clinical cases of thyroid cancer. It mentioned treatment and follow-up recommendations in a general framework, not patient-specific. Also, it provided practical and multifaceted emotional support advice to patients and caregivers regarding the next steps and adjusting to a new diagnosis. CONCLUSION: Our study is the first to evaluate the competence and reliability of ChatGPT in thyroid cancer. Although ChatGPT is moderately competent in obtaining information about thyroid cancer, it has not yet been determined to be sufficiently competent and reliable in case management. It has been found effective in guiding patients and their relatives regarding emotional support.

Effect of Music Therapy on Pain During Thyroid Fine Needle Aspiration Biopsy; A Randomized Controlled Clinical Trial.

INTRODUCTION: High-resolution ultrasonography devices have led to the increased detection of thyroid nodules and the need for fine-needle aspiration biopsy (FNAB). However, FNAB is an invasive procedure that can cause discomfort and pain. Music therapy has been used for centuries to alleviate pain, and our clinical trial was conducted to investigate its impact on pain scores during thyroid FNAB. MATERIALS AND METHODS: We conducted a randomized, controlled clinical trial, including adult patients undergoing thyroid FNAB. We evaluated the nonpharmacological intervention of listening to music before and during thyroid FNAB. We used a slow, nonlyrical, flowing melody with a tempo of 60 to 80 beats per minute as a therapeutic intervention for managing anxiety and pain. It had low tones, minimal percussion, and a volume of around 60 dB. The Beck Anxiety Inventory and Visual Pain Scale were used. RESULTS: The study included 529 patients assigned to either the music group (n = 258, 48.7%) or the control group (n = 271, 51.2%). The patients were categorized into subgroups based on either a single nodule (73.63%) or multiple nodules (24.18%). When all patients or single nodule and multiple data are examined separately, the intervention group showed statistically significantly lower pain scores than the control group. CONCLUSION: Our study is among the first on this topic and the largest in the available literature to demonstrate that listening to music during FNAB significantly reduces pain and anxiety. Music therapy is an effective, safe, and noninvasive intervention that can improve patient care and reduce distress and pain.

Incidental thyroid nodules on COVID-19-related thoracic tomography scans: a giant cohort.

INTRODUCTION: Computerized thoracic tomography (CT) imaging was extensively employed, especially in the early months of the COVID-19 pandemic. An incidental thyroid nodule (ITN) is defined as a nodule not previously detected or suspected clinically but identified via an imaging study. The present study aimed to determine the incidence of thyroid nodules incidentally detected in thoracic CTs for the suspicion of COVID-19 pneumonia. MATERIALS AND METHODS: Adult patients who underwent thoracic CT in our hospital for COVID-19 management were retrospectively identified between March 2020 and September 2020. Medical information registered in the hospital and national health system was reviewed. The prevalence of incidental thyroid nodules at CT, thyroid function test results of patients with incidental lesions, correlation of CT findings with ultrasonography (US) findings, and fine-needle aspiration biopsy (FNAB) results were evaluated. RESULTS: We analyzed 35,113 patients who had COVID-19-indicated CT scans. There was information about the thyroid gland in CT reports of 3049 patients. The prevalence of ITN was 3.82% (1343/35,113 patients) and thyroid heterogeneity was 1.11% (388/35,113 patients). While it was explicitly stated that no pathology was found in the patient's thyroid gland in 3.75% of patients (1318/35,113), no information was given about the thyroid gland in 91.32% of the patients (32064/35,113). Thus, the number of patients informed about their thyroid was 3049 (8.68%) and the number of patients with thyroid pathology was 1731 (4.93%). It was observed that 308 of 1731 patients (17.80%) had follow-up thyroid US. An FNAB was indicated in 238 patients (87.50%). Of the 238 patients with indication for biopsy, only 115 (48.31%) underwent a thyroid FNAB. The cytological diagnosis was benign in 59 (51.30%), non-diagnostic in 30 (26.08%), atypia of uncertain significance in 22 (19.13%), and suspected follicular neoplasia/follicular neoplasia in four patients (3.46%). Thyroidectomy was performed in six more patients due to large nodules and the final diagnosis was benign in two and papillary thyroid cancer in three patients. CONCLUSION: Increased use of thoracic CT during the COVID-19 pandemic probably enabled improved detection of ITNs. In this large-scale study, the prevalence of thyroid nodules reported with thoracic CT was 3.82%, while thyroid cancer was detected in 1.30% of patients evaluated with US. We recommend against using thoracic CT scans as a direct means of assessing thyroid disease owing to the low number of detected cancer cases in our cohort of 35,113 patients. However, thoracic CT scans obtained for various reasons might provide the opportunity for early diagnosis and treatment of thyroid disease, including cancers.

A Story of Serendipities: From Phlorizin to Gliflozins.

Diabetes has been acknowledged since ancient times. However, it was only during the late 1800s that we realized that the primary organ for blood glucose regulation was the pancreas. The 20th century witnessed insulin purification, which revolutionized the treatment of diabetes maigre; this was followed by the development of oral antidiabetic drugs. The sodium-glucose cotransporter 2 inhibitors or gliflozins are the latest class. Unique cardio- and renoprotective effects separate them from other oral antidiabetic drugs. Here, we present the history behind the development of these inhibitors, arguably the hottest and the most pleasant topic in nephrology. The first serendipity was Koninck and Stas (assistants to Prof. Van Mons, a renowned pomology expert); these researchers isolated a crystalline glycoside called phloridzin (phlorizin) from the bark of apple trees while working at their boss's nursery. Their discovery was published in German in 1835. The second serendipity, after a half century, was from Prof. von Mering, who decided to administer phlorizin to dogs. Oskar Minkowski initially observed polyuria than glucosuria. Insightfully, von Mering postulated that phlorizin affects kidneys. In 1887, they reported that phlorizin induced glucosuria in people with diabetes. The third serendipity was that phlorizin causes several gastrointestinal side effects and has poor oral bioavailability. The first phlorizin-based drug to enter trials was T-1095. The first clinically available gliflozin was dapagliflozin, receiving approval in Europe and the United States in 2012 and 2014, respectively. The 2015 EMPA-REG Outcome trial reported extremely satisfying results that no one expected. Subsequent trials and real-world data have resulted in changes in all impactful guidelines. The impact of these agents on heart failure and chronic kidney disease seems independent of their antidiabetic properties. More than 100 years after von Mering's original discovery, descendants of phlorizin are fast becoming the most inspiring medicine for the 21st century physician.

Differentiated thyroid cancer: effect on quality of life, depression, and anxiety.

CONTEXT: Thyroid cancer is the most common endocrine cancer, the lifelong risk for which is approximately 1%. Despite favorable prognosis and well-tolerated treatment modalities, numerous studies have shown that thyroid cancer survivors have impaired health-related quality of life (HRQoL). Patients are also more frequently affected by depression and anxiety. OBJECTIVE: We aimed to evaluate HRQoL, depression, and anxiety status in female patients with DTC. DESIGN, SUBJECTS, AND METHODS: We compared HRQoL, depression, and anxiety status in 114 female thyroid cancer survivors with 110 healthy subjects via a cross-sectional design. For this purpose, we utilized short-form 36 (SF-36), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). RESULTS: The majority of the patients (82%) were stage I. Fifty-seven patients (51%) received radioiodine treatment. Regarding HRQoL, depression, and anxiety between groups, thyroid cancer survivors did worse on every aspect of SF-36 than the control group (p < 0.05). Thyroid cancer survivors had higher BDI and BAI scores (p < 0.05). In those receiving RAI, the dose of RAI, lymph node dissection, and tumor stage did not affect SF-36, depression, and anxiety scores. Duration since diagnosis also did not affect results. CONCLUSION: Our study further confirms the observation that survivors of DTC have impaired HRQoL. Furthermore, they are more likely to suffer from anxiety and depression.

Mini-review: pump therapy in endocrinology & metabolism beyond diabetes.

The first pump developed by Dr. Kadish and his team in 1963 aimed to "continue subcutaneous insulin infusion". The number of patients using insulin pumps has increased since the 1980s. This historical perspective has labeled pump therapy in endocrinology and metabolism synonymous with insulin pumps. However, certain other hormonal disorders might also benefit from this kind of treatment. Pump therapy is currently the best approach to achieve physiological mimicry. Furthermore, it may help in overcoming pharmacokinetic issues or allergies. Until now, hormone replacement via pumps has been a salvage method for complex cases at the expense of increased costs. However, it is believed that applications of pump treatment will widen in the future owing to the rapidly evolving technology. In this mini review, data on pump use for patients with adrenal insufficiency, hypogonadism, hypoparathyroidism, congenital adrenal hyperplasia, and congenital hyperinsulinism have been briefly summarized. The study has aimed at covering all the relevant clinical studies and important case reports/series. METHODS: A systematic literature search has been conducted on PubMed database seeking articles published until May 2021 using a combination of the following Medical Subject Headings terms and keywords: pump "OR" continue infusion "AND" (adrenal insufficiency "OR" Addison "OR" hydrocortisone "OR" hypoparathyroidism "OR teriparatide" "OR" somatostatin "OR" hypogonadism "OR" hypoglycemia "OR" endocrinology "OR" hormone replacement). In addition, the reference publications in the identified articles have also been reviewed.

TCF7L2 (rs7903146) But Not CDKAL1 (rs7754840) Gene Polymorphisms Increase the Risk of New-Onset Diabetes After Kidney Transplant.

OBJECTIVES: Incidence of new-onset diabetes after transplant negatively affects graft and patient survival. Obesity, impaired fasting glucose before transplant, and a history of diabetes in first-degree relatives are well-defined risk factors. TCF7L2 and CDKAL1 gene polymorphisms have been implicated in the pathogenesis. We investigated the effect of single gene polymorp-hisms of TCF7L2 (rs7903146) and CDKAL1 (rs7754840) on new-onset diabetes in renal transplant recipients. MATERIALS AND METHODS: We evaluated 239 renal transplant recipients. TCF7L2 and CDKAL1 gene polymorphisms were assessed by polymerase chain reaction. RESULTS: Mean patient age was 43 ± 13 years. There were 148 male patients (61.9%), and 91 were female (38.1%). New-onset diabetes was detected in 55 patients (23%). In 20 cases (36%), the glycemic disorder was transient; 61% of patients required insulin therapy. In terms of CDKAL1, 108 patients had the wild-type allele, 112 had a single-allele mutation, and 19 had a 2-allele mutation (45.2%, 46.9%, and 7.9%, respectively). In terms of TCF7L2, 163 of the patients had the wild-type allele, 49 had a single-allele mutation, and 27 had a 2-allele mutation (68%, 20%, and 11%, respectively). New-onset diabetes-related factors were age at transplant, body mass index after transplant (calculated as weight in kilograms divided by height in meters squared), tacrolimus, mycophenolate, and TCF7L2 polymorphism but not CDKAL1 polymorphism. After multiple regression analysis, the effect of TCF7L2 polymorphism persisted. A single allelic change resulted in a risk factor 1.4 times higher for new-onset diabetes after transplant (P = .043; 95% CI, 1.142-1.874) and a double allelic change was 2.7 times higher (P < .01; 95% CI, 1.310-4.073) Conclusions: TCF7L2 (rs7903146) gene polymorphism is an independent risk factor for new-onset diabetes in Turkish renal transplant patients. This study is the first in Turkey to show the distribution and effect of these genes in kidney transplant patients.