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Bio

Bio

I grew up in the east bay area and was diagnosed with type 1 diabetes at age 12. I studied electrical engineering and computer science at U.C. Berkeley (Go Bears!) with the hope of applying my knowledge to diabetes technology. The significance of clinical practice became clear to me after my younger sisters also developed diabetes. I am devoting my life to advancing the care of diabetes in patients of all ages.

Clinical Focus

  • Endocrinology
  • Diabetes and Metabolism

Academic Appointments

Honors & Awards

  • Alpha Omega Alpha, National medical honor society (2017)
  • Stephen Bechtel Endowed Fellow, Stanford Child Health Research Institute (2017)
  • Outstanding Teaching as a House Officer, University of Southern California (2014)
  • Gold Humanism Honor Society, Gold Foundation (2011)

Professional Education

  • Board Certification: American Board of Pediatrics, Pediatric Endocrinology (2019)
  • Board Certification: American Board of Internal Medicine, Endocrinology, Diabetes and Metabolism (2018)
  • Fellowship: Stanford University Endocrinology Fellowship (2019) CA
  • Fellowship: Stanford University Pediatric Endocrinology Fellowship (2019) CA
  • Board Certification: American Board of Internal Medicine, Internal Medicine (2015)
  • Board Certification: American Board of Pediatrics, Pediatrics (2015)
  • Residency: LACplusUSC Internal Medicine and Pediatric Residency (2015) CA
  • Medical Education: University of California Davis School of Medicine (2011) CA

Contact

  • Stanford Children's Health Specialty Services Sunnyvale 1195 W Fremont Ave Sunnyvale, CA 94087
    • Tel: (408) 426-5590
    Fax: (650) 725-8375
  • Mary L Johnson Specialty Services 730 Welch Rd Palo Alto, CA 94304
    • Tel: (650) 721-1811
    Fax: (650) 725-8375
  • Endocrinology Academic Office 300 Pasteur Dr Rm S025 MC 5103 Stanford, CA 94305
    • Tel: (650) 725-2908
    Fax: (650) 498-5823

Teaching

2020-21 Courses

Publications

All Publications

  • Optimizing Basal Insulin Dosing. The Journal of pediatrics Lal, R. A., Maahs, D. M. 2019

    View details for DOI 10.1016/j.jpeds.2019.07.030

    View details for PubMedID 31383469

  • Realizing a Closed-Loop (Artificial Pancreas) System for the Treatment of Type 1 Diabetes. Endocrine reviews Lal, R. A., Ekhlaspour, L., Hood, K., Buckingham, B. 2019

    Abstract

    Recent, rapid changes in the treatment of type 1 diabetes have allowed for commercialization of an "artificial pancreas" which is better described as a closed-loop controller of insulin delivery. This review presents the current state of closed-loop control systems and expected future developments with a discussion of the human factor issues in allowing automation of glucose control. The goal of these systems is to minimize or prevent both short and long-term complications from diabetes and to decrease the daily burden of managing diabetes. The closed-loop systems are generally very effective and safe at night, have allowed for improved sleep and have decreased the burden of diabetes management overnight. However, there are still significant barriers to achieving excellent daytime glucose control while simultaneously decreasing the burden of daytime diabetes management. These systems utilize a subcutaneous continuous glucose sensor, an algorithm that accounts for the current glucose and rate of change of the glucose, and the amount of insulin which has already been delivered in order to safely deliver insulin to control hyperglycemia, while minimizing the risk of hypoglycemia. The future challenge will be to allow for full closed-loop control with minimal burden on the patient during the day alleviating meal announcements, carbohydrate counting, alerts and maintenance. The human factors involved with interfacing with a closed-loop system and allowing the system to take control of diabetes management are significant. It is important to find a balance between enthusiasm and realistic expectations and experiences with closed loop.

    View details for DOI 10.1210/er.2018-00174

    View details for PubMedID 31276160

  • Diabetes Technology and Therapy in the Pediatric Age Group. Diabetes technology & therapeutics Maahs, D. M., Lal, R., Shalitin, S. 2019; 21 (S1): S123?S137

    View details for DOI 10.1089/dia.2019.2510

    View details for PubMedID 30785328

  • Fluoroscopic-assisted laparoscopic retrieval of retained glucose sensor wire from the omentum. Clinical case reports Sang, A. X., Lal, R. n., August, A. n., Danzer, E. n., Buckingham, B. n., Mueller, C. M. 2019; 7 (9): 1717?20

    Abstract

    We describe a case in which retained wires from a continuous glucose monitor were removed from the abdominal wall and peritoneum of a 6-year-old boy. We highlight a concern for continuous glucose monitor use in children and discuss surgical techniques used to retrieve tiny, mobile objects from complex body cavities.

    View details for DOI 10.1002/ccr3.2348

    View details for PubMedID 31534734

    View details for PubMedCentralID PMC6745354

  • One Year Clinical Experience of the First Commercial Hybrid Closed-Loop. Diabetes care Lal, R. A., Basina, M. n., Maahs, D. M., Hood, K. n., Buckingham, B. n., Wilson, D. M. 2019

    Abstract

    In September 2016, the U.S. Food and Drug Administration approved the Medtronic 670G "hybrid" closed-loop system. In Auto Mode, this system automatically controls basal insulin delivery based on continuous glucose monitoring data, but requires users enter carbohydrates and blood glucose for boluses. To track real-world experience with this first commercial closed-loop device, we prospectively followed pediatric and adult patients starting the 670G system.This was a 1-year prospective observational study of patients with type 1 diabetes starting the 670G system between May 2017 and May 2018 in clinic.A total of 84 patients received 670G and consented, 5 never returned for follow-up, with 79 (aged 9-61 years) providing data at 1 week and 3, 6, 9, and/or 12 months after Auto Mode initiation. For the 86% (68 out of 79) with 1-week data, 99% (67 out of 68) successfully started. By 3 months, at least 28% (22 out of 79) stopped using Auto Mode; at 6 months, 34% (27 out of 79); at 9 months, 35% (28 out of 79); and by 12 months, 33% (26 out of 79). The primary reason for continuing Auto Mode was desire for increased time in range. Reasons for discontinuation included sensor issues in 62% (16 out of 26), problems obtaining supplies in 12% (3 out of 26), hypoglycemia fear in 12% (3 out of 26), multiple daily injection preference in 8% (2 out of 26), and sports in 8% (2 out of 26). At all visits, there was a significant correlation between hemoglobin A1c (HbA1c) and Auto Mode utilization.While Auto Mode utilization correlates with improved glycemic control, a focus on usability and human factors is necessary to ensure use of Auto Mode. Alarms and sensor calibration are a major patient concern, which future technology should alleviate.

    View details for DOI 10.2337/dc19-0855

    View details for PubMedID 31548247

  • Long-Acting Growth Hormone Preparations in the Treatment of Children. Pediatric endocrinology reviews : PER Lal, R. A., Hoffman, A. R. 2018; 16 (Suppl 1): 162?67

    Abstract

    Human growth hormone (hGH), which had been in use since 1958, was supplanted by recombinant human growth hormone (rhGH) in 1985 for those with growth hormone deficiency (GHD). Adherence to daily subcutaneous growth hormone is challenging for patients. Thus, several companies have pursued the creation of long acting rhGH. These agents can be divided broadly into depot formulations, PEGylated formulations, pro-drug formulations, non-covalent albumin binding GH and GH fusion proteins. Nutropin Depot is the only long acting rhGH ever approved by the U.S. Food and Drug Administration, and it was removed from the market in 2004. Of the approximately seventeen candidate drugs, only a handful remain under active clinical investigation or are commercially available.

    View details for PubMedID 30378794

  • Advances in Care for Insulin-Requiring Patients Without Closed Loop. Diabetes technology & therapeutics Lal, R. A., Buckingham, B., Maahs, D. M. 2018; 20 (S2): S285?S291

    View details for PubMedID 29916743

  • Advances in Care for Insulin-Requiring Patients Without Closed Loop DIABETES TECHNOLOGY & THERAPEUTICS Lal, R. A., Buckingham, B., Maahs, D. M. 2018; 20: 85?91

    View details for DOI 10.1089/dia.2018.0084

    View details for Web of Science ID 000435570300012

  • A Case Report of Hypoglycemia and Hypogammaglobulinemia: DAVID syndrome in a patient with a novel NFKB2 mutation. journal of clinical endocrinology and metabolism Lal, R. A., Bachrach, L. K., Hoffman, A. R., Inlora, J., Rego, S., Snyder, M. P., Lewis, D. B. 2017

    Abstract

    DAVID syndrome (Deficient Anterior pituitary with Variable Immune Deficiency) is a rare disorder in which children present with symptomatic ACTH deficiency preceded by hypogammaglobulinemia from B-cell dysfunction with recurrent infections, termed common variable immunodeficiency (CVID). Subsequent whole exome sequencing studies have revealed germline heterozygous C-terminal mutations of NFKB2 as either a cause of DAVID syndrome or of CVID without clinical hypopituitarism. However, to the best of our knowledge there have been no cases in which the endocrinopathy has presented in the absence of a prior clinical history of CVID.A previously healthy 7 year-old boy with no history of clinical immunodeficiency, presented with profound hypoglycemia and seizures. He was found to have secondary adrenal insufficiency and was started on glucocorticoid replacement. An evaluation for autoimmune disease, including for anti-pituitary antibodies, was negative. Evaluation unexpectedly revealed hypogammaglobulinemia (decreased IgG, IgM, and IgA). He had moderately reduced serotype-specific IgG responses following pneumococcal polysaccharide vaccine. Subsequently, he was found to have growth hormone (GH) deficiency. Six years after initial presentation, whole exome sequencing revealed a novel de novo heterozygous NFKB2 missense mutation c.2596A>C (p.Ser866Arg) in the C-terminal region predicted to abrogate the processing of the p100 NFKB2 protein to its active p52 form.Isolated early-onset ACTH deficiency is rare and C-terminal region NFKB2 mutations should be considered as an etiology even in the absence of a clinical history of CVID. Early immunologic evaluation is indicated in the diagnosis and management of isolated ACTH deficiency.

    View details for DOI 10.1210/jc.2017-00341

    View details for PubMedID 28472507

  • Clinical Use of Continuous Glucose Monitoring in Pediatrics. Diabetes technology & therapeutics Lal, R. A., Maahs, D. M. 2017; 19 (S2): S37-S43

    View details for DOI 10.1089/dia.2017.0013

    View details for PubMedID 28541138

  • An unusual cause of hyperglycemia JOURNAL OF POSTGRADUATE MEDICINE Lal, R., Loomba-Albrecht, L. A., Bremer, A. A. 2011; 57 (4): 343?46

    View details for DOI 10.4103/0022-3859.90092

    View details for Web of Science ID 000298626200018

    View details for PubMedID 22120869

  • Amyloid-beta and Glucose Metabolism in Alzheimer's Disease JOURNAL OF ALZHEIMERS DISEASE Furst, A. J., Lal, R. A. 2011; 26: 105-116

    Abstract

    This study used PET with the amyloid-? (A?) imaging agent 11 C Pittsburgh Compound-B (PIB) and the glucose metabolic tracer 18F-fluorodeoxyglucose (FDG) to map the relationship of A? deposition to regional glucose metabolism in Alzheimer's disease (AD). Comparison of 13 AD patients' FDG scans with 11 healthy controls confirmed a typical temporo-parietal hypometabolic pattern in AD. In contrast, PIB distribution-volume-ratios showed a distinct pattern of specific tracer retention in fronto-temporo-parietal regions and striatum in AD with peaks in left frontal cortex, precuneus, temporal cortex, striatum and right posterior cingulate. There were no region-to-region or within region correlations between FDG and PIB uptake in PIB positive AD patients but when the impact of A? load on glucose metabolism was assessed via probabilistic maps, increased amyloid burden was coupled with decreased metabolism in temporo-parietal regions and the posterior cingulate. However, importantly, severe A? burden was not associated with comparable metabolic decreases in large parts of the frontal lobes, the striatum and the thalamus.

    View details for DOI 10.3233/JAD-2011-0066

    View details for Web of Science ID 000297842800008

    View details for PubMedID 21971455

  • Amyloid-beta and Glucose Metabolism in Alzheimer's Disease HANDBOOK OF IMAGING THE ALZHEIMER BRAIN Furst, A. J., Lal, R. A., Ashford, J. W., Rosen, A., Adamson, M., Bayley, P., Sabri, O., Furst, A., Black, S. E., Weiner, M. 2011; 2: 235?46

    View details for DOI 10.3233/978-1-60750-793-2-235

    View details for Web of Science ID 000351445400023

  • Striatal Dopamine and Working Memory CEREBRAL CORTEX Landau, S. M., Lal, R., O'Neil, J. P., Baker, S., Jagust, W. J. 2009; 19 (2): 445-454

    Abstract

    Recent studies have emphasized the importance of dopamine projections to the prefrontal cortex (PFC) for working memory (WM) function, although this system has rarely been studied in humans in vivo. However, dopamine and PFC activity can be directly measured with positron emission tomography (PET) and functional magnetic resonance imaging (fMRI), respectively. In this study, we examined WM capacity, dopamine, and PFC function in healthy older participants in order to test the hypothesis that there is a relationship between these 3 factors. We used the PET tracer 6-[18F]fluoro-L-m-tyrosine to measure dopamine synthesis capacity in the striatum (caudate, putamen), and event-related fMRI to measure brain activation during different epochs (cue, delay, probe) of a WM task. Caudate (but not putamen) dopamine correlated positively with WM capacity, whereas putamen (but not caudate) dopamine correlated positively with motor speed. In addition, delay-related fMRI activation in a left inferior prefrontal region was related to both caudate dopamine and task accuracy, suggesting that this may be a critical site for the integration of WM maintenance processes. These results provide new evidence that striatal dopaminergic function is related to PFC-dependent functions, particularly brain activation and behavioral performance during WM tasks.

    View details for DOI 10.1093/cercor/bhn095

    View details for Web of Science ID 000262518800019

    View details for PubMedID 18550595

    View details for PubMedCentralID PMC2733326

  • A beta Amyloid and Glucose Metabolism in Three Variants of Primary Progressive Aphasia ANNALS OF NEUROLOGY Rabinovici, G. D., Jagust, W. J., Furst, A. J., Ogar, J. M., Racine, C. A., Mormino, E. C., O'Neil, J. P., Lal, R. A., Dronkers, N. F., Miller, B. L., Gorno-Tempini, M. L. 2008; 64 (4): 388-401

    Abstract

    Alzheimer's disease (AD) is found at autopsy in up to one third of patients with primary progressive aphasia (PPA), but clinical features that predict AD pathology in PPA are not well defined. We studied the relationships between language presentation, Abeta amyloidosis, and glucose metabolism in three PPA variants using [11C]-Pittsburgh compound B ([11C]PIB) and [18F]-labeled fluorodeoxyglucose positron emission tomography ([18F]FDG-PET).Patients meeting PPA criteria (N = 15) were classified as logopenic aphasia (LPA), progressive nonfluent aphasia (PNFA), or semantic dementia (SD) based on language testing. [11C]PIB distribution volume ratios were calculated using Logan graphical analysis (cerebellar reference). [18F]FDG images were normalized to pons. Partial volume correction was applied.Elevated cortical PIB (by visual inspection) was more common in LPA (4/4 patients) than in PNFA (1/6) and SD (1/5) (p < 0.02). In PIB-positive PPA, PIB uptake was diffuse and indistinguishable from the pattern in matched AD patients (n = 10). FDG patterns were focal and varied by PPA subtype, with left temporoparietal hypometabolism in LPA, left frontal hypometabolism in PNFA, and left anterior temporal hypometabolism in SD. FDG uptake was significant asymmetric (favoring left hypometabolism) in PPA (p < 0.005) but not in AD.LPA is associated with Abeta amyloidosis, suggesting that subclassification of PPA based on language features can help predict the likelihood of AD pathology. Language phenotype in PPA is closely related to metabolic changes that are focal and anatomically distinct between subtypes, but not to amyloid deposition patterns that are diffuse and similar to AD.

    View details for DOI 10.1002/ana.21451

    View details for Web of Science ID 000260845000007

    View details for PubMedID 18991338

    View details for PubMedCentralID PMC2648510

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