Background: Despite established guidelines and increasing national hospital quality metrics, achieving consistent inpatient glycemic control remains challenging. A system-wide glucose data monitoring dashboard can help consolidate and visualize key metrics to support quality improvement (QI) and standardize care. Methods: A web-based diabetes dashboard was implemented across 7 hospitals within a large health care system to monitor monthly data from the electronic health record. Metrics included patient-days with hypoglycemia (<70 mg/dL), hyperglycemia (mean >180 mg/dL), in-hospital mortality, hospital length of stay (LOS), and 30-day readmissions to the emergency department (ED) or inpatient/observation (IP/OBS). A total of 455 303 admissions were analyzed between January 2018 and March 2025, comparing pre-implementation (2018-2022) to post-implementation (2023-2025). Statistical analyses included t tests or Wilcoxon rank-sum tests. Given differences between the large academic site and 6 community hospitals, a difference-in-differences analysis was performed to evaluate impact by hospital type. Results: After implementation of the dashboard, patient-days with hypoglycemia decreased from 4.81% to 4.15%, hyperglycemia from 25.30% to 23.46%, mortality from 2.69% to 2.13%, and LOS from 7.56 to 7.29 days (all P < .01). Emergency department and IP/OBS readmissions increased slightly (P < .01 and P = .01, respectively). Comparing the community hospitals to the academic, statistically significant reductions were observed in hypoglycemia, hyperglycemia, and mortality but with increased ED readmissions. There were no differences in LOS or IP/OBS readmission. Conclusions: Implementation of a system-wide electronic dashboard was associated with improved glycemic control, mortality, and LOS. Dashboards can effectively support multidisciplinary collaboration and QI in diverse hospital settings.

CONTEXT:Severe thyrotoxicosis and thyroid storm have a high morbidity and mortality risk and are commonly managed with antithyroid drugs. In some patients, a combination therapy with medications and thyroidectomy as definite treatment are required. Therapeutic Plasma Exchange (TPE) can be used as a temporizing measure to achieve thyroid hormone normalization and to prevent perioperative complications before surgery. OBJECTIVE:We describe 6 cases of severe thyrotoxicosis and/or thyroid storm who underwent TPE as a bridge to thyroidectomy and present the clinical characteristics and outcomes. We aim to propose a preoperative thyroid hormone target. METHODS:We collected data of 6 patients who were diagnosed with severe thyrotoxicosis or thyroid storm between April 2023 and April 2024 and that were treated with TPE due to high mortality risk or refractoriness to medical treatment. Data collected included the baseline clinical characteristics, laboratory data, clinical progress, and outcomes. Thyroid hormone levels at diagnosis, before initiation of TPE, and before thyroidectomy were compared using statistical analysis. RESULTS:Four of 6 patients underwent thyroidectomy, and 2 patients died due to multiorgan dysfunction. The mean free T4 (fT4) level at diagnosis was 4.8 ng/dL (reference range, 0.8-1.8 ng/dL), 5.4 ng/dL pre-TPE, and 2.6 ng/dL prethyroidectomy, resulting in a mean difference of 2.8 ng/dL (51.7%) reduction (95% CI, 1.1-4.5; P = .01). The number of TPE treatments to reach a preoperative fT4 level of 2.5 ng/dL was 5.5 treatments (P = .03). CONCLUSION:These results reflect efficacy of TPE as a bridge to thyroidectomy and suggest that a preoperative fT4 goal of 2.5 to 3.3 can be considered in patients with severe thyrotoxicosis and thyroid storm that are refractory to medical treatment.

The global rise in obesity and cardiometabolic disease represents a major public health concern and contributes significantly to cardiovascular morbidity and mortality. Contemporary Western dietary patterns and excess adiposity are strongly associated with atherosclerotic cardiovascular disease. Although pharmacologic therapies have expanded, lifestyle interventions remain the cornerstone of prevention and management. However, identifying sustainable and effective dietary approaches continues to be challenging given the wide range of available nutrition regimens. Intermittent fasting (IF) has emerged as a promising strategy for weight reduction and metabolic improvement. In this article, we review the physiological effects of IF, including metabolic switching, ketosis, and improvements in insulin sensitivity and inflammatory regulation. We also evaluate clinical evidence regarding the impact on cardiovascular risk, as well as its safety and tolerability. We examine the hormonal responses to IF based on sex. While early studies raised concerns regarding potential reproductive and endocrine disturbances, recent data suggest beneficial effects in both males and females. IF may modestly reduce testosterone in men without impairing muscle mass or strength and may improve metabolic and reproductive outcomes in women, particularly those with hyperandrogenic conditions such as polycystic ovarian syndrome, with favorable effects also observed in postmenopausal women, especially when combined with physical activity.

Patients with cystic fibrosis often have significant baseline endocrine comorbidities that may worsen following organ transplantation, necessitating long-term surveillance, and close follow-up. Post-transplant glycemic control is critical due to the risk of worsening cystic fibrosis-related diabetes or new-onset post-transplant diabetes mellitus associated with glucocorticoids, calcineurin inhibitors, and additional metabolic stressors. Poor glycemic control is linked to increased rates of hospitalization, graft dysfunction, rejection, morbidity, and mortality. Intensive patient education, close glucose monitoring, and timely initiating or escalating antidiabetes medication use are fundamental care goals. Cystic fibrosis also increases baseline osteoporosis and fracture risk due to gonadal dysfunction, chronic malabsorption, and frequent GC use, which may be further exacerbated post-transplant due to additional insults from high dose GCs and immunosuppression. Routine assessment on bone health, including bone mineral density and vitamin D monitoring, is essential to prevent osteoporosis and reduce fracture risk. In addition, adrenal insufficiency remains an under-recognized complication related to prolonged GC use, and clinicians should maintain a lower threshold to actively screen for adrenal insufficiency routine visits. Furthermore, post-transplant improvements in fertility and increased use of assisted reproductive technologies underscore the growing need for comprehensive, multidimensional monitoring protocols. Optimizing endocrine health and providing structured preconception counseling are essential to prevent unplanned post-transplant pregnancies and mitigating adverse maternal and fetal outcomes. This comprehensive review explores key challenges in endocrine care among patients with cystic fibrosis, with special emphasis on post-transplant patients, including glycemic control, bone health, adrenal and thyroid dysfunction, and reproductive endocrine management.

This 76-minute webcast features a conversation about "Obesity and the Heart"-the focus of Issue 21.2. Led by the issue's editor, the discussion engages the authors on emerging themes and lessons learned while researching and writing the articles. View the video at https://vimeo.com/event/4867850.

Obesity and overweight have become increasingly significant conditions, affecting more than 70% of the adult population in the United States. These conditions are caused by a combination of factors, including genetic, behavioral, environmental, and medical influences. Obesity is a major risk factor for cardiovascular and metabolic diseases. A comprehensive treatment plan for individuals with obesity must recognize the chronic nature of the condition and offer strategies for weight reduction and long-term cardiometabolic benefits. Over the past several decades, multiple therapeutic options have been implemented to address weight loss, appetite regulation, and caloric expenditure, with the goal of reducing the burden of obesity and improving cardiovascular outcomes. Pharmacological treatment of obesity has focused primarily on the central regulation of appetite and food intake behavior. The introduction of incretin agonists for obesity treatment has ushered in a new era of cardiometabolic health, with a multitargeted mechanism that achieves weight loss, glycemic control, decreased cardiovascular mortality, and other metabolic benefits. This review explores the current pharmacological options and the future of obesity treatment.

Basal bolus insulin regimen (BB) is standard practice for managing hyperglycemia. For optimal outcomes with BB, the nursing workflow of timing the point of care glucose (POC-G) measurement with insulin pharmacokinetics is essential. In real-world hospital settings, this is a challenge and can result in iatrogenic hypoglycemia and hyperglycemia. We aimed to improve hypoglycemia by changing nursing practice to reduce the time interval between POC-G measurement and insulin administration. A best practice advisory (BPA) was created to fire within the EHR at the time of insulin administration to alert the nurse to repeat a POC-G if the prior measurement was over 30 minutes for fast acting (FA) or intermediate acting (IA) or over 60 minutes for long acting (LA) insulin. Retrospective data was collected from our hospital system in all hospitalized patients receiving subcutaneous insulin for four months before and after implementation of the BPA. Of total insulin administrations (n=300,462), BPA was fired on 90% (n=270,370) with 94% (n=253,551) acknowledgment rate. The median length of time (LoT) between POC-G and insulin administration pre-BPA to post-BPA decreased from 42 min to 23 min for FA and IA, and from 52 min to 29 min for LA insulin. Concurrently, the median patient days with hypoglycemia defined as POC-G <70 mg/dL reduced from 4.8% to 4.3%, a relative reduction of 10.4%. A real-time EHR based BPA for nurses improved timing of POC-G with insulin administration and resulted in reduction of hypoglycemia in a real-world hospital setting. Disclosure B. Patham: None. V. Saldivar: None. S.L. Yarlagadda: None. A.R. Sadhu: Advisory Panel; Abbott Diagnostics.

Objective: Preexisting diabetes mellitus (DM) and post-transplant diabetes mellitus (PTDM) impact outcomes post solid organ transplantation (SOT). Benefits of tirzepatide are well studied in DM but not in patients after SOT. This study describes safety and efficacy of tirzepatide in SOT. Methods: Retrospective data was collected on 16 SOT patients with DM/PTDM on insulin, oral agents or both after initiation of tirzepatide for 6 months. [Table 1] Changes from baseline in A1C and weight (efficacy), and eGFR and tacrolimus levels (safety) were assessed. Results: From baseline to 6 months, mean A1C reduced by 14.8% (-1.3%) and weight by 6.9% (-5.4 kg), but were not statistically significant. eGFR and tacrolimus levels were unchanged. [Table 2] Conclusion: Tirzepatide may be a safe and effective drug in SOT patients. Larger studies are warranted. Disclosure S. Dowlatshahi: None. B. Patham: None. A. Kansara: None. A.W. Rogers: None. A.R. Sadhu: Advisory Panel; Abbott Diagnostics.

Calcineurin inhibitors (CNIs) frequently correlate with disruption in glucose metabolism. Tacrolimus (TAC), currently a cornerstone in triple-drug immunosuppression following solid organ transplantation, stands out as the most potent CNI. It has been associated with islet cell damage and a reduction in insulin secretion, potentially contributing to post-transplant diabetes mellitus and, rarely, DKA. We describe five cases of DKA occurring in post-transplant patients undergoing TAC treatment.

This innovative multi-disciplinary activity increased the value of cadaveric dissection, integration of content across courses, and promoted self-directed learning of integrated clinicopathology material.

Insulin remains the mainstay of treatment for inpatient hyperglycemia in the United States and Canada. However, some other countries commonly use noninsulin agents such as metformin and sulfonylureas, and several trials have demonstrated the efficacy and safety of incretin-based agents in patients with type 2 diabetes who are admitted to noncritical care medicine and surgery services. There is a high degree of interest in alternative glucose-lowering strategies to achieve favorable glycemic outcomes with lower risks of hypoglycemia. In this case series, we highlight the challenges of inpatient glycemic management and the need for alternatives to the traditional basal-bolus insulin regimen. Additional investigation will be imperative to validate the safety and efficacy of appropriate insulin and noninsulin treatments and to further develop guidelines that are applicable in real-world hospital settings.

Context Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the "real world," insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. Objective This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. Methods This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (-18.03; CI, -22.46 to -12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

Background: Amidst the coronavirus disease 2019 (COVID-19) pandemic, continuous glucose monitoring (CGM) has emerged as an alternative for inpatient point-of-care blood glucose (POC-BG) monitoring. We performed a feasibility pilot study using CGM in critically ill patients with COVID-19 in the intensive care unit (ICU). Methods: Single-center, retrospective study of glucose monitoring in critically ill patients with COVID-19 on insulin therapy using Medtronic Guardian Connect and Dexcom G6 CGM systems. Primary outcomes were feasibility and accuracy for trending POC-BG. Secondary outcomes included reliability and nurse acceptance. Sensor glucose (SG) was used for trends between POC-BG with nursing guidance to reduce POC-BG frequency from one to two hours to four hours when the SG was in the target range. Mean absolute relative difference (MARD), Clarke error grids analysis (EGA), and Bland-Altman (B&A) plots were calculated for accuracy of paired SG and POC-BG measurements. Results: CGM devices were placed on 11 patients: Medtronic (n = 6) and Dexcom G6 (n = 5). Both systems were feasible and reliable with good nurse acceptance. To determine accuracy, 437 paired SG and POC-BG readings were analyzed. For Medtronic, the MARD was 13.1% with 100% of readings in zones A and B on Clarke EGA. For Dexcom, MARD was 11.1% with 98% of readings in zones A and B. B&A plots had a mean bias of −17.76 mg/dL (Medtronic) and −1.94 mg/dL (Dexcom), with wide 95% limits of agreement. Conclusions: During the COVID-19 pandemic, CGM is feasible in critically ill patients and has acceptable accuracy to identify trends and guide intermittent blood glucose monitoring with insulin therapy.

Guidelines recommend discontinuing oral antidiabetes drugs (OADs) on admission and initiating basal bolus insulin therapy. In the real world, concurrent OAD use with insulin is common and may affect outcomes. We conducted a large, retrospective study of 4558 patients age >18, admission >48 hours, and administered insulin >75% of days. 847 (18.58%) were administered OADs along with insulin within the first 2 days. Insulin therapy was categorized into 3 groups based on observed prescribing practices: sliding scale (SS), basal and scheduled rapid acting bolus (BB), Basal and rapid acting as needed (B+). Each group was analyzed for glucose control by days with hypoglycemia (any <70 mg/dl), hyperglycemia (mean >180 mg/dl) or euglycemia (no hypo- or hyperglycemia). Clinical outcomes included length of stay, 30/60 day readmission, and hospital mortality. Previously identified patient and provider factors that influence the choice of therapy were controlled using propensity score adjusted models. There were no statistical significant differences in hyperglycemia, euglycemia or clinical outcomes between BB or B+ compared to SS. However, hypoglycemia occurred 2 times more in BB compared to SS. B+ also had a higher trend of hypoglycemia. In our hospital system, basal insulin along with OADs resulted in more hypoglycemia. Further investigation is needed on optimizing these choices of therapy. Disclosure B. Patham: None. S. Chikermane: None. A. Vadhariya: None. M.L. Johnson: None. A.R. Sadhu: None.

Background: Evidence has shown that low thyroid hormone levels may lead to worse prognosis including a higher mortality rate in patients with heart failure (HF). Thyroid replacement increases cardiac output and exercise performance without causing significant adverse events. The purpose of this study is to compare levothyroxine doses in patients with and without HF.Methods: This single center, retrospective cohort study compared levothyroxine doses in ambulatory hypothyroid patients with a history of HF to those without a history of HF. Patients were stratified into three groups: no HF, HF with reduced ejection fraction (HFrEF, EF<40%), and other types of HF. The primary endpoint of average levothyroxine dose was analyzed using multivariable linear regression with variables determined a priori.Results: Three hundred patients were included in the study with 100 patients in each arm. Average levothyroxine doses (mcg/kg) were 1.5 ± 0.7, 1.6 ± 0.8, and 1.6 ± 0.9 for no HF, other types of HF, HFrEF, respectively (p= .61). Factors found to be significantly related to levothyroxine dosing included gender, drug-drug interactions, and the timing of clinic visit to lab draw. No differences were found in secondary outcomes including TSH levels, free T4, T3, and percentage of patients with elevated thyroid-stimulating hormone (TSH) among HFrEF, other types of HF, and no HF patients. Among HF patients, average ejection fractions were also similar comparing patients with elevated TSH, normal TSH, and low TSH.Conclusion: The dose of levothyroxine was not significantly different in HF patients compared to patients without HF.

Guidelines recommend basal bolus insulin for inpatient hyperglycemia management based on studies performed in patients with type 2 diabetes without any corticosteroid therapy. However, in the “real-world,” corticosteroid use is common and complicates management. To better understand insulin use in corticosteroid related hyperglycemia, we conducted a large, retrospective study of patients who were: age >18 years, admission >48 hours, administered insulin >75% of admission, AND administered corticosteroids within the first 2 days of admission. Patients receiving IV insulin or no insulin within two days were excluded. Insulin therapy was categorized into 3 groups based on observed prescribing practices: (a) sliding scale (SS, n=481) (b) basal bolus (BB, n=356), (c) Basal plus (B+, n=386). Each group was analyzed for glucose control: days with hypoglycemia (any <70mg/dl), hyperglycemia (mean >180 mg/dl) or euglycemia (no hypo- or hyperglycemia) and clinical outcomes of length of stay (LOS), 30/60-day readmission, and hospital mortality. Patient and provider factors that influence choice of therapy were controlled using propensity score adjusted models. BB had fewer hyperglycemic days and lower LOS, albeit more hypoglycemia than SS. B+ had higher hyperglycemic and hypoglycemic days than SS. For corticosteroid related hyperglycemia, BB was a superior insulin regimen in reducing hyperglycemia and LOS. Disclosure B. Patham: None. A. Vadhariya: None. M.L. Johnson: None. S.D. Yande: None. A.R. Sadhu: None.