Background:The increasing use of continuous glucose monitor (CGM) necessitates a review of variables that impact accuracy and interrupt use. Manufacturer recommendations include removing CGMs before diagnostic imaging, such as X-ray and computed tomography (CT). Early removal and replacement of CGM components present financial, clinical, and psychosocial burdens to the wearer and interrupt optimal management of diabetes for pediatric patients who receive a total pancreatectomy with islet autotransplantation (TPIAT). The study's aim was to evaluate the effect of scatter dose exposure during X-ray or CT if the CGM remained intact but outside the field of view (FoV). Materials and Methods:Participants were followed through the first 3 months after TPIAT surgery, managed diabetes with an insulin pump and CGM, and were routinely exposed to diagnostic imaging. Participants' CGMs were unshielded by a protective apron during any X-ray or CT procedures for the duration of the study period, and the transmitter was collected after expiration or removal. Glucometer data was collected from hospital records and home glucometer downloads. Mixed models were used to analyze absolute differences between matched CGM and glucometer values, and Clarke error grid analyses (EGA) were performed. Scatter dose exposure was derived using anthropomorphic phantoms and calculated retrospectively. Results:A total of 14 patients (median 12.2 years, 64% female) received a median of five diagnostic imaging procedures with a median cumulative scatter dose of 559 µGy. The absolute difference between the CGM and glucometer values was not significantly associated with the cumulative scatter dose (p=0.17) or time from TPIAT (p=0.24) when analyzed in a mixed model. Regardless of scatter dose exposure, time from TPIAT, or glucometer, ≥98% of glucose values fell within zones A and B on EGA. Conclusion:Scatter dose exposure from diagnostic imaging did not affect the clinical accuracy of CGM values for the duration of transmitter use. Leaving CGM components in place when not in the FoV during diagnostic imaging successfully mitigated interruptions to use and undue burden or cost to participants.

Objective: To describe management strategies that contributed to optimal outcomes in pediatric recipients of a total pancreatectomy with islet autotransplantation (TPIAT). Research Design and Methods: We provide a comprehensive report of the approach to endocrine management of the pediatric TPIAT recipient from initial evaluation through the first 4 years postsurgery. We performed a retrospective review of the endocrine outcomes of TPIAT recipients to describe the impact of this approach on post-TPIAT glycemic management. Results: Outcome data from 86 TPIAT recipients were reviewed. At 12 months post-TPIAT (n = 82), the median HbA1C was 6.0% (25-75th percentile 5.6-6.7), at 18 months (n = 56) HbA1C was 6.4% (5.6-7.5), at 2 years (n = 46) HbA1C was 6.4% (5.6-7.4), at 3 years (n = 31) HbA1C was 6.5% (5.5-8.1), and at 4 years (n = 16) HbA1C was 7.2% (6.2-8.3). Conclusions: Pediatric patients at our institution have favorable endocrine outcomes as evidenced by median HbA1C under the goal of 6.5% through the initial 3 years by following our modified management protocols.

We previously published that insulin pump initiation immediately after IV insulin therapy was associated with improved post-surgical glycemic outcomes compared to multiple daily injections (MDI) in pediatric patients following a total pancreatectomy with islet autotransplantation (TPIAT). We investigated metabolic outcomes of this population at one-year post-TPIAT to assess if the improved outcomes in the early pump group were sustained over time. We retrospectively reviewed 40 patients post-TPIAT previously studied at 10-days post-surgery (15 used MDI and 25 used pump therapy immediately post-ICU, and all were discharged on pump therapy). Data analyzed included: demographics, islet equivalents per kilogram (IEQ/kg) transplanted, exogenous insulin use, and baseline vs. one-year (via mixed meal testing) HbA1c, fasting glucose, insulinogenic index, and the area under the curve (AUC) for insulin and c-peptide. More patients were off insulin at one year in the early pump group compared to the MDI group (45% vs. 13%, p = 0.07). Of all patients off insulin, 100% of the early pump users weaned off by six months post-TPIAT compared to 30% of the MDI users. Two known variables associated with favorable insulin outcomes, lower age and higher IEQ/kg, were not significantly different between groups. Fasting glucose was lower in the early pump group compared to the MDI group (median 97 vs. 122 mg/dL, p = 0.003), while AUC c-peptide was greater in early pump users at one-year post-TPIAT but did not reach significance (median 57.0 vs. 50.3 ng/mL × minutes, p = 0.14). Other metabolic outcomes did not differ between groups. Despite lower median age and higher IEQ/kg in the MDI group, the early pump group had a lower fasting glucose. Younger TPIAT age (p = 0.02) and early pump users (p = 0.04) were significantly associated with insulin independence at one year. This study was limited by sample size. Early pump use may have long-term benefits in post-TPIAT endogenous insulin secretion.

Introduction: Long term insulin requirements following TPIAT range from insulin independence to full (high) dose daily insulin (>0.5 units/kg/day). Markers of islet cell autoimmunity are used in children to predict type 1 diabetes risk. However, no studies have explored whether an association exists between islet cell autoimmunity and insulin requirement following TPIAT in children. We hypothesized that children with islet cell autoantibody formation were more likely to have a persistent insulin requirement following TPIAT. Methods: All children who underwent TPIAT between 2015 and 2021 at our institution were eligible for inclusion. Islet cell autoimmunity was defined as positive islet cell autoantibody screen for one or more of the following types of autoantibodies: Glutamic Acid Decarboxylase (GAD), Islet Antigen-2 (IA-2), Insulin (IAA), or Zinc Transporter 8 (ZnT8). Patients were screened prior to TPIAT and every six months following TPIAT for up to three years. In all, 73 patients were included in the analysis. Total daily insulin dose was determined for each patient at each time interval. Chi-square or Fisher’s exact tests were used to compare proportions. Results: Of patients with 12-month data (n=38), 47% of islet cell autoantibody negative patients were off insulin vs 26% of antibody positive patients (p=0.19). This trend was significant at 18, 24, and 36 months after TPIAT. At 18 months, 90% (9/10) of antibody negative patients were off insulin vs 29% (4/14) of antibody positive patients (p=0.005). At 24 months, 73% (8/11) of antibody negative patients were off insulin vs 23% (3/13) of antibody positive patients (p=0.04). At 36 months, 100% (8/8) of antibody negative patients were off insulin compared to 0% (0/9) of antibody positive patients (p<0.0001). Conclusions: The presence of pancreatic islet cell antibodies was associated with persistent insulin requirement after TPIAT. Disclosure A.R.Lavik: None. C.M.O.Lowe: None. S.E.Tellez: None. L.Hornung: None. C.Heinzman: None. J.D.Nathan: None. M.Abu-el-haija: None. D.A.Elder: None.

Background: Hepatic steatosis has been described as a common finding in adults following total pancreatectomy with islet autotransplantation (TPIAT) but it is unknown if this occurs in children and adolescents.Objectives: To define the frequency of post-TPIAT hepatic steatosis in a sample of children and adoles-cents and to identify clinical predictors of incident steatosis post-TPIAT.Methods: In this prospective study, consecutive participants at least 1-month post-TPIAT underwent a liver MRI with proton density fat fraction (PDFF) and blood draw at our pediatric academic medical center between April 2021 and January 2022. Comparison clinical pre-TPIAT liver MRI or ultrasound and insulin use and graft function data were extracted from the medical record. T-tests were used for the comparison of means across continuous variables between participants with and without post-TPIAT steatosis.Results: A total of 20 participants (mean: 13 +/- 4 years; 12 female) were evaluated. Mean liver PDFF at research MRI was 7.4 +/- 6.2% (range: 2-25%). Seven participants (35%) had categorical hepatic steatosis (PDFF>5%) post-TPIAT, five of whom had pre-TPIAT steatosis, reflecting a 13% (2/15; 95% CI: 2-40%) incidence of post-TPIAT steatosis. Participant characteristics were not significantly different between subgroups with and without post-TPIAT steatosis. Mean PDFF at research MRI was not different between graft function subgroups (7.5% optimal/good vs. 7.3% marginal/failure; p 1/4 .96).Conclusion: Our study shows a moderate prevalence but low incidence of hepatic steatosis in a small sample of children and adolescents post-TPIAT. This study raises questions about a causal relationship between TPIAT and hepatic steatosis.(c) 2022 IAP and EPC. Published by Elsevier B.V. All rights reserved.

Background: Caregivers of pediatric recipients of a TPIAT must receive extensive education prior to discharge home. Retrospective review found caregivers were often surprised by the amount of education required and were not prepared to learn while their child was recovering from surgery. Expectations of preparedness were not uniformly reinforced with caregivers, despite available resources. We aimed to provide caregivers with comprehensive education pre-surgery in line with programmatic goals to reduce the inpatient length of stay (LOS) post-TPIAT. Method: We reviewed education time and days for 17 pre-intervention patients (September 2019-August 2020) , and 20 post-intervention patients (August 2020-October 2021) . Diabetes education time was consistently documented in the chart and represented the largest proportion of education needed prior to discharge. Pre-intervention patients received a printed binder of diabetes education and met with diabetes educators at least once in the 6 months prior to surgery. Post-intervention patients received an email with digital links to the timeline and expectations of pre-surgery education, modules for education on diabetes, medication administration, and feeding tube care, and received follow-up phone calls. The intervention was developed using the Plan-Do-Study-Act (PDSA) model of improvement. Results: Prior to the intervention, patients averaged 7minutes of inpatient education spread over an average of 6.4 days. After implementation, patients averaged 575 minutes spread over 4.7 days. There was no cost associated with the development of the intervention. Conclusion: We created our intervention in response to the goal of reducing LOS and adapted it to the low-resource and staffing constraints of a pandemic. We generated a free, sustainable tool that used existing resources. Though our project is ongoing, we are encouraged that inpatient education has been reduced from 7to 575 minutes and from 6.4 to 4.7 days. Disclosure R.E.Ellison: Other Relationship; AbbVie Inc. S.E.Tellez: None.

Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure for patients with chronic pancreatitis and poor quality of life. Euglycemia is critical for islet cell survival and engraftment. We reviewed clinical care practice and hypothesized that early in-hospital transition from intravenous insulin to insulin pump therapy, managed by an endocrine unit trained on post-surgical care, would improve glucose control and impact the length of hospital stay. We completed a retrospective analysis of 40 pediatric patients who underwent TPIAT. Comparative hospitalized postoperative groups included those who received insulin intravenously, followed by multiple daily injections, subsequently managed by pump therapy (n = 14), versus those who received insulin intravenously followed by early pump therapy provided on the endocrine unit trained to manage post-surgical patients (n = 26). The outcomes analyzed included percentage of blood glucoses in target (4.44–6.66 mmol/L (80–120 mg/dL)), hypoglycemia (<3.33 mmol/L (<60 mg/dL)) and hyperglycemia (>7.77 mmol/L (>140 mg/dL)), blood glucose variability, and length of hospital unit stay post-ICU. Hospitalized patients with early transition to pump therapy on a specialized endocrine unit had a higher proportion of glucose values in the target range (61% vs. 51%, p = 0.0003), a lower proportion of hyperglycemia (15% vs. 19%, p = 0.04), and a lower proportion of hypoglycemia, though not statistically significant (3.4% vs. 4.4%, p = 0.33). Early pump users also had lower variability in glucose values over 10 days post-intravenous insulin (p = 0.001), and the post-transition median length of stay was shorter by 5 days (median: 11.5 vs. 16.5 days, p = 0.005). Early in-hospital pump therapy managed by the specialized endocrine unit improved glucose outcomes and reduced the duration of in-unit stay.

Objective: To assess the degree, duration, and mean absolute relative difference (MARD) of false values per continuous glucose monitoring (CGM) systems when hydroxyurea (HU) is administered. Research Design and Methods: Inpatient glucometer and CGM data from 16 post-total pancreatectomy (TPIAT) patients using Dexcom Professional G4 and 6 patients using Dexcom G6 were analyzed after daily dosing with HU. Timing of HU dosing and up to 2 weeks of sensor and glucometer values were assessed in each patient. Results: A false elevation (>20 mg/dL) of sensor readings were identified after HU dosing. The greatest discrepancy between glucometer and sensor readings occurred 0.5-2 hours after HU administration [G4 (mean 53 mg/dL, median 44 mg/dL, MARD 0.55), G6 (mean 67 mg/dL, median 72.5 mg/dL, MARD 0.79)]. The sensor and glucometer readings were <20 mg/dL mean and median, MARD 0.14 (G4) and <40mg/dL mean and median, MARD 0.18 (G6), by 6 hours after administration. All other prescribed medications were given multiple times each day and did not result in glucose value discrepancy. Conclusions: There is a false elevation of sensor glucose readings compared to glucometer values (up to 180 mg/dL (G4), 235 mg/dL (G6)) from 0.5hr to 6hr following HU administration. It is important to counsel a patient using a Dexcom CGM system and HU therapy on this finding and to advise reliance on glucometer testing for accurate glucose assessment up to 6 hours after HU administration. Disclosure S.E. Tellez: None. L. Hornung: None. J.D. Courter: None. M. Abu-El-Haija: None. J.D. Nathan: None. S. Lawson: None. D.A. Elder: None.

Abstract Treatment-induced neuropathy of diabetes (TIND) is a small fiber neuropathy precipitated by rapid correction of hyperglycemia. Literature on TIND in pediatric diabetes is scarce. We present 7 cases of TIND in children and young adults, increasing awareness of this condition in pediatric diabetes and broadening the scope of published knowledge.

Objective: To assess the degree, duration, mean absolute relative difference (MARD), and error analysis of discrepant values per continuous glucose monitoring (CGM) systems after hydroxyurea (HU) administration. Research Design and Methods: Inpatient glucometer and CGM data from 16 total pancreatectomy/islet autotransplantation patients using Dexcom Professional G4 and 12 patients using Dexcom G6 were analyzed after daily dosing with HU. Timing of HU dosing and median of 9.5 days of sensor and glucometer values were assessed per patient. Results: A large positive elevation of sensor readings was identified after HU dosing. The greatest discrepancy between glucometer and sensor readings occurred 0.5-2 h after HU administration [G4 (mean 3.0 mmol/L, median 2.4 mmol/L, MARD 55%), G6 (mean 4.2 mmol/L, median 4.6 mmol/L, MARD 91%)]. The discrepancy was <1.1 mmol/L, mean (-0.5 mmol/L) and median (-0.5 mmol/L), MARD 14% (G4) and <1.1 mmol/L, mean (0.3 mmol/L) and median (0.3 mmol/L), MARD 17% (G6), by 6 h after administration. Error analysis with the G6 system found 94% of pairs in clinically acceptable range by 6-9 h after HU administration. Aspirin, also given once daily, did not result in glucose value discrepancy with the G6 system but variability was observed with the G4 system. Conclusions: There was marked elevation of sensor glucose readings compared with glucometer values [up to 13.9 mmol/L (G4), 13 mmol/L (G6)] from 0.5 to 6 h after HU administration. It is important to counsel a patient using a Dexcom CGM system and HU therapy on this finding and to advise reliance on glucometer testing for accurate glucose assessment up to 6-9 h after HU administration.

Objective: Total pancreatectomy with islet autotransplantation (TPIAT) is a surgical procedure for patients with chronic pancreatitis who experience debilitation and poor quality of life. Glucose targets are critical for islet survival. We hypothesized that early transition from intravenous insulin to insulin pump therapy would improve glucose control and impact hospital duration. Research Design and Methods: We performed a retrospective analysis of 40 patients who underwent TPIAT. Prior to 2016, post-operative insulin was delivered intravenously and transitioned to multiple daily injections (MDI) followed by pump administration (n=14). After 2016, post-operative insulin was delivered intravenously followed by early transition to pump therapy (n=26). Outcomes analyzed between groups included: percentage of blood glucoses in target (80-120 mg/dL), hypoglycemia (<60 mg/dL) and hyperglycemia (>140 mg/dL), blood glucose variability, and length of stay after transition off intravenous insulin. Results: Patients with early transition to pump therapy had a higher proportion of glucose values in target range (p=0.0003), a lower proportion of hyperglycemia (p=0.04), and a lower proportion of hypoglycemia, though not significant (p=0.33). In patients with early pump transition, variability in glucose values decreased over the first 10 days post-intravenous insulin (p=0.001) and post-transition median length of stay was shorter by 5 days (p=0.005). Conclusions: Early pump therapy in this population achieved tighter glycemic control and reduced duration of stay. Disclosure S.E. Tellez: None. L. Hornung: None. J.D. Courter: None. M. Abu-El-Haija: None. J.D. Nathan: None. S. Lawson: None. D.A. Elder: None.