Showing papers by "Ochsner Medical Center published in 2017"

Herpes Zoster and Tofacitinib: Clinical Outcomes and the Risk of Concomitant Therapy

Abstract: Objective Patients with rheumatoid arthritis (RA) are at increased risk of herpes zoster (HZ), and the risk appears to be increased in patients treated with tofacitinib. The aim of this study was to evaluate whether concomitant treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or glucocorticoids (GCs) contributes to the increased risk of HZ in RA patients treated with tofacitinib. Methods HZ cases were identified from the databases of 2 phase I, 9 phase II, 6 phase III, and 2 long-term extension studies of tofacitinib in RA patients. Crude incidence rates (IRs) of all HZ events (serious and nonserious) per 100 patient-years (with 95% confidence intervals [95% CIs]) were calculated for unique patients. Within phase III studies, we described HZ rates according to concomitant csDMARD treatment and baseline GC use. A multivariable Cox proportional hazards regression model was used to evaluate HZ risk factors across studies. Results Across all studies (6,192 patients; 16,839 patient-years), HZ was reported in 636 tofacitinib-treated patients (IR 4.0, 95% CI 3.7–4.4). In most cases (93%), HZ was classified as nonserious, and the majority of patients (94%) had involvement of only 1 dermatome. HZ IRs varied across regions, from 2.4 (95% CI 2.0–2.9) in Eastern Europe to 8.0 (95% CI 6.6–9.6) in Japan and 8.4 (95% CI 6.4–10.9) in Korea. Within phase III studies, HZ IRs varied according to tofacitinib dose, background csDMARD treatment, and baseline use of GCs. The IRs were numerically lowest for monotherapy with tofacitinib 5 mg twice daily without GCs (IR 0.56 [95% CI 0.07–2.01]) and highest for tofacitinib 10 mg twice daily with csDMARDs and GCs (IR 5.44 [95% CI 3.72–7.68]). Age, GC use, tofacitinib dose, and enrollment within Asia were independent risk factors for HZ. Conclusion Patients receiving treatment with tofacitinib and GCs appear to have a greater risk of developing HZ compared with patients receiving tofacitinib monotherapy without GCs.

SAGES guidelines for the use of laparoscopy during pregnancy

Abstract: Surgical interventions during pregnancy should minimize fetal risk without compromising the safety of the mother. Favorable outcomes for the pregnant woman and fetus depend on accurate and timely diagnosis with prompt intervention. Surgeons must be aware of data regarding differences in techniques used for pregnant patients to optimize outcomes. This document provides specific recommendations and guidelines to assist physicians in the diagnostic workup and treatment of surgical conditions in pregnant patients, focusing on the use of laparoscopy.

Differential effects of glucagon-like peptide-1 receptor agonists on heart rate

Abstract: While glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are known to increase heart rate (HR), it is insufficiently recognized that the extent varies greatly between the various agonists and is affected by the assessment methods employed. Here we review published data from 24-h time-averaged HR monitoring in healthy individuals and subjects with type 2 diabetes mellitus (T2DM) treated with either short-acting GLP-1 RAs, lixisenatide or exenatide, or long-acting GLP-1 RAs, exenatide LAR, liraglutide, albiglutide, or dulaglutide (N = 1112; active-treatment arms). HR effects observed in two independent head-to-head trials of lixisenatide and liraglutide (N = 202; active-treatment arms) are also reviewed. Short-acting GLP-1 RAs, exenatide and lixisenatide, are associated with a transient (1–12 h) mean placebo- and baseline-adjusted 24-h HR increase of 1–3 beats per minute (bpm). Conversely, long-acting GLP-1 RAs are associated with more pronounced increases in mean 24-h HR; the highest seen with liraglutide and albiglutide at 6–10 bpm compared with dulaglutide and exenatide LAR at 3–4 bpm. For both liraglutide and dulaglutide, HR increases were recorded during both the day and at night. In two head-to-head comparisons, a small, transient mean increase in HR from baseline was observed with lixisenatide; liraglutide induced a substantially greater increase that remained significantly elevated over 24 h. The underlying mechanism for increased HR remains to be elucidated; however, it could be related to a direct effect at the sinus node and/or stimulation of the sympathetic nervous system, with this effect related to the duration of action of the respective GLP-1 RAs. In conclusion, this review indicates that the effects on HR differ within the class of GLP-1 RAs: short-acting GLP-1 RAs are associated with a modest and transient HR increase before returning to baseline levels, while some long-acting GLP-1 RAs are associated with a more pronounced and sustained increase during the day and night. Findings from recently completed trials indicate that a GLP-1 RA-induced increase in HR, regardless of magnitude, does not present an increased cardiovascular risk for subjects with T2DM, although a pronounced increase in HR may be associated with adverse clinical outcomes in those with advanced heart failure.

Gaps and barriers in the control of blood glucose in people with type 2 diabetes.

Abstract: Background: Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature. Methods: An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online. Results: Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed. Conclusion: Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.

Carotid Bulb Webs as a Cause of "Cryptogenic" Ischemic Stroke.

Abstract: BACKGROUND AND PURPOSE: Carotid webs are intraluminal shelf-like filling defects at the carotid bulb with recently recognized implications in patients with recurrent ischemic stroke. We sought to determine whether carotid webs are an under-recognized cause of “cryptogenic” ischemic stroke and to estimate their prevalence in the general population. MATERIALS AND METHODS: A retrospective review of neck CTA studies in young patients with cryptogenic stroke over the past 6 years (n = 33) was performed to determine the prevalence of carotid webs compared with a control group of patients who received neck CTA studies for reasons other than ischemic stroke (n = 63). RESULTS: The prevalence of carotid webs in the cryptogenic stroke population was 21.2% (95% CI, 8.9%–38.9%). Patients with symptomatic carotid webs had a mean age of 38.9 years (range, 30–48 years) and were mostly African American (86%) and women (86%). In contrast, only 1.6% (95% CI, 0%–8.5%) of patients in the control group demonstrated a web. Our findings demonstrate a statistically significant association between carotid webs and ischemic stroke (OR = 16.7; 95% CI, 2.78–320.3; P = .01). CONCLUSIONS: Carotid webs exhibit a strong association with ischemic stroke, and their presence should be suspected in patients lacking other risk factors, particularly African American women.

SCAI appropriate use criteria for peripheral arterial interventions: An update.

Abstract: Andrew J. Klein, MD, FSCAI1 | Michael R. Jaff, DO, FSCAI2 | Bruce H. Gray, DO, FSCAI3 | Herbert D. Aronow, MD, MPH, FSCAI4 | Robert M. Bersin, MD, MPH, FSCAI5 | Larry J. Diaz-Sandoval, MD, FSCAI6 | Robert S. Dieter, MD, RVT, FSCAI7 | Douglas E. Drachman, MD, FSCAI8 | Dmitriy N. Feldman, MD, FSCAI9 | Osvaldo S. Gigliotti, MD, FSCAI10 | Kamal Gupta, MD, FSCAI11 | Sahil A. Parikh, MD, FSCAI12 | Duane S. Pinto, MD, MPH, FSCAI13 | Mehdi H. Shishehbor, DO, MPH, PhD, FSCAI14 | Christopher J. White, MD, MSCAI15

The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios

Abstract: The Global Partnership for Effective Diabetes Management has previously recommended the implementation of an interdisciplinary team (IDT) approach to type 2 diabetes (T2DM) management as one of 10 practical steps for health care professionals to help more people achieve their glycaemic goal. This article discusses some of the key contributors to success and also the challenges faced when applying IDT care, by examining case studies and examples from around the world. The real-world practices discussed show that implementing successful interdisciplinary care in diabetes is possible despite significant barriers such as established hierarchal structures and financial resource constraints. Instituting collaborative, integrated working relationships among multiple disciplines under strong leadership, together with enhanced and active communication and improved patient access to appropriate specialties is essential. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical. IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT, in whatever form, is paramount to enable the best care to be delivered.

Sex-related Differences in Outcomes Among Men and Women Under 55 Years of Age With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Results From the PROMETHEUS Study

Abstract: Young women undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) experience greater adverse events than men, potentially due to under-treatment. We sought to compare the 1-year outcomes by sex in patients ≤55 years of age from a contemporary PCI cohort. PROMETHEUS was a retrospective multicenter observational US study comparing outcomes in clopidogrel and prasugrel treated patients following ACS PCI. MACE was defined as a composite of death, myocardial infarction, stroke or unplanned revascularization. Clinically significant bleeding was defined as bleeding requiring transfusion or hospitalization. Hazard ratios were generated using multivariable Cox proportional hazards regression. The study cohort included 4,851 patients of which 1,162 (24.0%) were women and 3,689 (76.0%) were men. In this cohort, the prevalence of diabetes (41.0 vs. 27.9%) and chronic kidney disease (12.7 vs. 7.2%) was higher among women compared with men. Irrespective of sex, prasugrel was used in less than one-third of patients (31.8% in men vs. 28.1% in women, P = 0.01). Unadjusted, 1-year MACE (21.1% vs. 16.2%, P Women ≤ 55 years of age undergoing ACS PCI have significantly greater comorbidities than young men. Despite a higher risk clinical phenotype in women, prasugrel use was significantly lower in women than men. Female sex was associated with a significantly higher risk of 1-year MACE and bleeding than male sex, findings that are attributable to baseline differences. © 2016 Wiley Periodicals, Inc.

Aggressive Surgical Approach to the Management of Neuroendocrine Tumors: A Report of 1,000 Surgical Cytoreductions by a Single Institution.

Abstract: Background Neuroendocrine tumors (NETs) are rare neoplasms. Our group has treated more than 2,000 NET patients and has performed more than 1,000 surgical cytoreductive procedures. Study Design Records of 834 NET patients who underwent surgical cytoreduction at our institution were reviewed. Demographic information, intraoperative findings, extent of disease, complications, and survival rates were calculated. Results Eight hundred patients underwent 1,001 cytoreductive operations. Sixty-five percent had small bowel primaries. One hundred and thirty-eight patients presented with an unknown primary site, which was localized intraoperatively in 89% of these cases. The intraoperative complication rate was 9%. The incidence of intraoperative carcinoid crisis was 1%. Mean ± SD operative time was 368 ± 146 minutes. Mean ± SD hospital stay was 9 ± 10 days. Minor postoperative complications occurred after 43% of procedures and major postoperative complications were noted after 19% of procedures. The 30-day postoperative mortality rate was 2%. Median overall survival (OS) for patients with pancreatic NETs was 124 months. The 5-, 10-, and 20-year OS rates for patients with pancreatic NETs were 67%, 51%, and 36%, respectively. The life expectancy difference (between OS and actuarial survival) after surgical cytoreduction for patients with pancreatic NETs was 16.6 years. Median OS for patients with small bowel NETs was 161 months. The 5-, 10-, and 20-year OS rates for patients with small bowel NETs were 84%, 67% and 31%, respectively. The life expectancy difference after surgical cytoreduction for patients with small bowel NETs was 11.7 years. Conclusions Surgical cytoreduction in NET patients has low morbidity and mortality rates and results in prolonged survival. We believe that surgical cytoreduction should play a major role in the care of patients with NETs.

Accuracy of Medical Claims for Identifying Cardiovascular and Bleeding Events After Myocardial Infarction : A Secondary Analysis of the TRANSLATE-ACS Study.

Abstract: Importance Pragmatic clinical trial designs have proposed the use of medical claims data to ascertain clinical events; however, the accuracy of billed diagnoses in identifying potential events is unclear Objectives To compare the 1-year cumulative incidences of events when events were identified by medical claims vs by physician adjudication and to assess the accuracy of bill-identified events using physician adjudication as the criterion standard Design, Setting, and Participants This post hoc analysis of a clinical trial assessed the medical claims forms and records for all rehospitalizations at 233 US hospitals within 1 year of the index acute myocardial infarction (MI) of 12 365 patients enrolled in the Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome (TRANSLATE-ACS) study between April 1, 2010, and October 31, 2012 Fourteen patients (01%) died during the index hospitalization and were excluded from analysis Recurrent MI, stroke, and bleeding events were identified per theInternational Classification of Diseases, Ninth Revision, Clinical Modificationdiagnosis and procedural codes in medical bills These events were independently adjudicated by study physicians through medical record reviews using the prespecified criteria of recurrent MI and stroke and the bleeding definition by the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) scale Medical claims were reported on a Uniform Bill-04 claims form; claims were collected from all hospitals visited by patients enrolled in TRANSLATE-ACS Agreement between medical claims–identified events and physician-adjudicated events over the 12 months after discharge was assessed with the κ statistic Data were analyzed from January 30, 2015, to March 2, 2017 Main Outcomes and Measures Event rates within 1 year after MI Results Among 12 365 patients with acute MI, 8890 (719%) were men and mean (SD) age was 60 (116) years The cumulative 1-year incidence of events identified by medical claims was 43% for MI, 09% for stroke, and 50% for bleeding Incidence rates based on physician adjudication were 47% for MI, 09% for stroke, and 54% for bleeding Agreement between medical claims–identified and physician-adjudicated events was modest, with a κ of 076 (95% CI, 073 to 079) for MI and 055 (95% CI, 041 to 068) for stroke events In contrast, agreement between medical claims–identified and physician-adjudicated bleeding events was poor, with a κ of 024 (95% CI, 019 to 030) for any hospitalized bleeding event and 015 (95% CI, 011 to 020) for moderate or severe bleeding on the GUSTO scale Conclusions and Relevance Event rates at 1 year after MI were lower for MI, stroke, and bleeding when medical claims were used to identify events than when adjudicated by physicians Medical claims diagnoses were only modestly accurate in identifying MI and stroke admissions but had limited accuracy for bleeding events An alternative approach may be needed to ensure good safety surveillance in cardiovascular studies Trial Registration clinicaltrialsgov Identifier:NCT01088503

β-Lactam Therapy for Methicillin-Susceptible Staphylococcus aureus Bacteremia: A Comparative Review of Cefazolin versus Antistaphylococcal Penicillins

Abstract: Methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia is associated with high morbidity and mortality. Traditionally, antistaphylococcal penicillins (ASPs) have been considered the agents of choice for the treatment of MSSA bacteremia. Vancomycin has been demonstrated to have poorer outcomes in several studies and is only recommended for patients with severe penicillin allergies. Although cefazolin is considered as an alternative to the ASPs for patients with nonsevere penicillin allergies, cefazolin offers several pharmacologic advantages over ASPs, such as more convenient dosing regimens, and antimicrobial stewardship programs are increasingly using cefazolin as the preferential agent for MSSA infections as part of cost-saving initiatives. Concerns about susceptibility to hydrolysis by type A β-lactamases, particularly at high inocula seen in deep-seated infections such as endocarditis; selective pressures from unnecessary gram-negative coverage; and lack of comparative clinical data have precluded recommending cefazolin as a first-line therapy for MSSA bacteremia. Recent clinical studies, however, have suggested similar clinical efficacy but better tolerability, with lower rates of discontinuation due to adverse drug reactions, of cefazolin compared with ASPs. Other variables, such as adequate source control (e.g., intravascular catheter removal, debridement, or drainage) and enhanced pharmacodynamics through aggressive cefazolin dosing, may mitigate the role of cefazolin inoculum effect and factor into determining improved clinical outcomes. In this review, we highlight the utility of cefazolin versus ASPs in the treatment of MSSA bacteremia with a focus on clinical efficacy and safety.

Management of pulmonary neuroendocrine tumors.

Abstract: Neuroendocrine tumors (NETs) of the lung are divided into 4 major types: small cell lung cancer (SCLC), large cell neuroendocrine carcinoma (LCNEC), atypical carcinoid (AC) or typical carcinoid (TC). Each classification has distinctly different treatment paradigms, making an accurate initial diagnosis essential. The inconsistent clinical presentation of this disease, however, makes this difficult. The objective of this manuscript is to detail the diagnosis and management of the well differentiated pulmonary carcinoid (PC) tumors. A multidisciplinary approach to work up and treatment should be utilized for each patient. A multimodal radiological work-up is used for diagnosis, with contrast enhanced CT predominantly utilized and functional imaging techniques. A definitive diagnosis is based on tissue findings. Surgical management remains the mainstay of therapy and can be curative. In those with advanced disease, medical treatments consist of somatostatin analog (SSA) therapy, targeted therapy, chemotherapy or peptide receptor radionuclide therapy. SSAs are the standard of care in those with metastatic NETs, using either Octreotide long acting repeatable (LAR) or lanreotide as reasonable options, despite a scarcity of prospective data in PCs. Targeted therapies consist of everolimus which is approved for use in PCs, with various studies showing mixed results with other targeted agents. Additionally, radionuclide therapy may be used and has been shown to increase survival and to reduce symptoms in some studies. Prospective trials are needed to determine other strategies that may be beneficial in PCs as well as sequencing of therapy. Successful diagnosis and optimal treatment relies on a multidisciplinary approach in patients with lung NETs. Clinical trials should be used in appropriate patients.

Interferon-alpha-induced hepatitis C virus clearance restores p53 tumor suppressor more than direct-acting antivirals.

Abstract: The mechanism why hepatitis C virus (HCV) clearance by direct-acting antivirals (DAAs) does not eliminate the risk of hepatocellular carcinoma (HCC) among patients with advanced cirrhosis is unclear. Many viral and bacterial infections degrade p53 in favor of cell survival to adapt an endoplasmic reticulum (ER)-stress response. In this study, we examined whether HCV clearance by interferon-alpha or DAAs normalizes the ER stress and restores the expression of p53 tumor suppressor in cell culture. We found that HCV infection induces chronic ER stress and unfolded protein response in untransformed primary human hepatocytes. The unfolded protein response induces chaperone-mediated autophagy (CMA) in infected primary human hepatocytes and Huh-7.5 cells that results in degradation of p53 and induced expression of mouse double minute 2 (Mdm2). Inhibition of p53/Mdm2 interactions by small molecule (nutlin-3) or silencing Mdm2 did not rescue the p53 degradation, indicating that HCV infection induces degradation of p53 independent of the Mdm2 pathway. Interestingly, we found that HCV infection degrades p53 in a lysosome-dependent mechanism because lysosome-associated membrane protein 2A silencing restored p53 degradation. Our results show that HCV clearance induced by interferon-alpha-based antiviral therapies normalizes the ER-stress response and restores p53, whereas HCV clearance by DAAs does neither. We show that decreased expression of p53 in HCV-infected cirrhotic liver is associated with expression of chaperones associated with ER stress and the CMA response. Conclusion: HCV-induced ER stress and CMA promote p53 degradation in advanced liver cirrhosis. HCV clearance by DAAs does not restore p53, which provides a potential explanation for why a viral cure by DAAs does not eliminate the HCC risk among patients with advanced liver disease. We propose that resolving the ER-stress response is an alternative approach to reducing HCC risk among patients with cirrhosis after viral cure. (Hepatology Communications 2017;1:256-269).

Does Spanning a Lateral Lumbar Interbody Cage Across the Vertebral Ring Apophysis Increase Loads Required for Failure and Mitigate Endplate Violation.

Abstract: Study Design.Randomized Biomechanical Cadaveric Study—Level II.Objective.We aimed to elucidate that placing lateral lumbar interbody cages that span the stronger ring apophysis will require increasing loads for failure, decreasing rates of subsidence, regardless of bone density or endplate integrity

Workplace Bullying in Radiology and Radiation Oncology.

Abstract: Workplace bullying is common in health care and has recently been reported in both radiology and radiation oncology. The purpose of this article is to increase awareness of bullying and its potential consequences in radiology and radiation oncology. Bullying behavior may involve abuse, humiliation, intimidation, or insults; is usually repetitive; and causes distress in victims. Workplace bullying is more common in health care than in other industries. Surveys of radiation therapists in the United States, student radiographers in England, and physicians-in-training showed that substantial proportions of respondents had been subjected to workplace bullying. No studies were found that addressed workplace bullying specifically in diagnostic radiology or radiation oncology residents. Potential consequences of workplace bullying in health care include anxiety, depression, and health problems in victims; harm to patients as a result of victims' reduced ability to concentrate; and reduced morale and high turnover in the workplace. The Joint Commission has established leadership standards addressing inappropriate behavior, including bullying, in the workplace. The ACR Commission on Human Resources recommends that organizations take steps to prevent bullying. Those steps include education, including education to ensure that the line between the Socratic method and bullying is not crossed, and the establishment of policies to facilitate reporting of bullying and support victims of bullying.

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement.

Abstract: The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH. The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

Technology in Arthroplasty: Are We Improving Value?

Abstract: Total joint arthroplasty is regarded as a highly successful procedure. Patient outcomes and implant longevity, however, are related to proper alignment and position of the prostehses. In an attempt to reduce outliers and improve accuracy and precision of component position, navigation and robotics have been introduced. These technologies, however, come at a price. The goals of this review are to evaluate these technologies in total joint arthroplasty and determine if they add value. Recent studies have demonstrated that navigation and robotics in total joint arthroplasty can decrease outliers while improving accuracy in component positioning. While some studies have demonstrated improved patient reported outcomes, not all studies have shown this to be true. Most studies cite increased cost of equipment and longer operating room times as the major downsides of the technologies at present. Long-term studies are just becoming available and are promising, as some studies have shown decreased revision rates when navigation is used. Finally, there are relatively few studies evaluating the direct cost and value of these technologies. Navigation and robotics have been shown to improve component position in total joint arthroplasty, which can improve patient outcomes and implant longevity. These technologies offer a promising future for total joint arthroplasty.

Autoimmune Diabetes Presented with Diabetic Ketoacidosis Induced by Immunotherapy in an Adult with Melanoma.

Abstract: Introduction Immunotherapy has been approved for treatment of melanoma. Autoimmune endocrinopathies have been reported in trials involving immunotherapy but autoimmune diabetes has not been definitively linked to them. Here we describe a case of autoimmune diabetes presenting with DKA after receiving combined immunotherapy with anti-CTLA4 and anti-PD1 monoclonal antibodies. Case A 47year old gentleman with metastatic melanoma presented to our institution with confusion, abdominal pain and decreased oral intake. The patient had a history of diabetes on metformin which was discontinued two years prior. He was started on Novilumab/Iplimumab for metastatic melanoma. He had received two cycles of immunotherapy and treatment was initially well tolerated. However, eight days after the second cycle the patient developed lethargy, confusion, vomiting and abdominal pain. CT of the head was negative for intracranial abnormalities and without evidence of brain metastasis. His laboratory results included: serum sodium 126 mmol/L, potassium 6.7 mmol/L, BUN 55 mg/dL, creatinine 3.5, bicarbonate 5 mmol/L, chloride 94 mmol/L, albumin 3.2 g/dL. Serum beta-hydroxybuterate was elevated (4.7 mmol/L, N: 0.0-0.5 mmol/L) and the calculated anion gap was 43 mmol/L. Serum lipase elevated (535 u/L, N: 4-60 u/L). The diagnosis of diabetic ketoacidosis was made and he was started on intravenous fluids and insulin therapy. Given his history of metastatic melanoma, his DKA was initially thought to be secondary to pancreatic metastasis especially considering the elevated lipase level. A non-contrast CT of the abdomen showed no evidence of pancreatic metastasis. Interestingly, further investigation identified high serum titers of anti-glutamic acid decarboxylase (anti-GAD) antibodies (0.43 nmol/L, N: less than 0.02 nmol/L), a low C-peptide level (0.2 ng/ml, N: 0.9-5.5 ng/ml), supporting an autoimmune etiology of the diabetes. Other islet autoantibodies were not elevated and his Hemoglobin A1C was 8.0 percent . Discussion There are few case reports about diabetes and immunotherapy. Autoimmune mechanism was suggested as the culprit, although not all cases reported with positive antibodies. Moreover, it is unlikely that patient developed latent autoimmune diabetes (LADA); and not related to immunotherapy due to the course of LADA is quite more gradual and our patient presented with acute DKA few days post the second cycle. Physicians and patients should be aware that autoimmune disorder such as DKA may be a rare but important immunotherapy related adverse events.