bluuebunny/crossref_metadata_2025 huggingface dataset:
SAT-433 The Influence of Thyroid Autoimmunity on Pregnancy Outcome in Infertile Women
Authors: Takeshima Ken , Inagaki Yuko , Nishi Masahiro , Ariyasu Hiroyuki , Uraki Shinsuke , Morita Shuhei , Furukawa Yasushi , Inaba Hidefumi , Iwakura Hiroshi , Utsunomiya Tomoko , Akamizu Takashi
Published: May 2020

Background: Women with subclinical hypothyroidism (SCH) and thyroid autoimmunity (TAI) reportedly have high risks of miscarriage and preterm birth. Infertile women undergoing assisted reproductive technology (ART) are recommended for levothyroxine (L-T4) supplementation to maintain TSH levels below 2.5 mIU/mL according to ATA guideline; however, insufficient evidence exists to determine whether L-T4 treatment for infertile women with TSH levels between 2.5 and 5.0 mIU/mL. Objective: To clarify the influence of TAI on pregnancy in infertile women under L-T4 treatment to maintain TSH levels below 2.5 mIU/mL, and to compare its influence depending on fertility treatments. Methods: A total of 595 infertile women who visited a fertility clinic between January 2013 and December 2015 were prospectively recruited to this study. Five patients with Graves’ disease were excluded and remained 590 women were included in the analysis. Infertile women with TSH levels above 2.5 mIU/mL were treated with L-T4 followed by evaluation of fertility status and pregnancy outcomes. Factors affecting pregnancy were analyzed statistically depending on fertility treatments. Written informed consent was obtained from all patients, and the study protocol was approved by the Ethics Committee. Results: The proportion of SCH and thyroid peroxidase antibodies (TPOAb).positivity was 19.6% and 10.4%, respectively. Women who did not become pregnant were older than those who became pregnant (p=0.003), but no influence of thyroid-associated factors on pregnancy was confirmed. Pregnancy outcome contrarily showed that women who had a miscarriage were older (p<0.001) and higher TPOAb titers (p=0.038) than those who had a live birth. In addition, higher age (OR 26.4, p<0.001) and high TPOAb titer (OR 11.8, p=0.043) were decided as risk factors for miscarriage through multiple logistic regression analysis. Among women who treated with intrauterine insemination, TPOAb titers were higher in women who had a miscarriage than in those who had a live birth (p=0.040). We further focused on the difference between ART methods including in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). Women undergoing IVF had higher TPOAb titers in women who had miscarriage than those who had a live birth (p=0.023), but in women undergoing ICSI there was no association between TPOAb titers and pregnancy outcome. Conclusion: Infertile women with high TPOAb titers are susceptible to miscarriage despite appropriate L-T4 treatment. The influence of TPOAb titers as well as TPOAb positivity on pregnancy should be considered, when undergoing fertility treatments.
SAT-628 Risk Factors Associated with 30-Day and 90-Day Readmission in Persons with Diabetic Foot Ulcers
Authors: Dawkins Makeda , Baskaran Inthuja , Izard Stephanie , Elzanaty Mohammed , Zhang Meng , Bissoonauth Aditya A , Oropallo Alisha , Kaplan Sally , Rao Amit , Myers Alyson K
Published: May 2020

Background Diabetic foot ulcers (DFU) are the leading cause of lower-extremity amputations among patients with diabetes (DM)1. 15% of patients with DM develop DFU, with the potential for progression to osteomyelitis or gangrene with suboptimal glycemic control. Repeated readmissions are not only a negative prognostic indicator for these patients, but also contributes to increasing healthcare costs.

Areas of Uncertainty Previous studies have examined associations among demographics, comorbidities and DFU, and the value of Hemoglobin A1c (HbA1c) and C-reactive protein (CRP) as a prognostic indicator and monitoring tool for progression and regression, respectively3,4. However, no studies to date have examined medical or pharmaceutical factors contributing to 30-day and 90-day readmission.

Methods A retrospective chart review was conducted examining 397 patients with type 2 diabetes readmitted for DFU between 2014 and 2019. Variables were summarized using descriptive statistics, t-tests, chi-square, and logistic regressions.

Results Majority of patients were white males with a BMI over 30 and HbA1c >7%. Patients with 30-day readmission were more likely to be using anticoagulants (30.00% vs. 17.24%, p= 0.0493). Patients with 90-day readmission were more likely to be discharged home with healthcare services (55.67% vs. 39.85%, p=0.0341) or to a skilled nursing facility (7.22% vs. 6.02%, p=0.0341). Although not statistically significant, patients with both 30-day and 90-day readmissions were also more likely to have HbA1c >7, while those with a 90-day readmission had higher CRP levels.

Conclusions DFU patients with suboptimal glycemic control were more likely to experience a 30-day and 90-day readmission. Predicators for readmission in this population include: anticoagulation use, discharge to a skilled nursing facility or discharge home with healthcare services. As a result, patients not on anticoagulation, as well as those discharged home without services or to rehabilitation facilities have a reduced risk of readmission.

1.

Lazzarini PA, Clark D, Derhy PH. What are the major causes of lower limb amputations in a major Australian teaching hospital? The Queensland Diabetic Foot Innovation Project, 2006 – 2007. 2011;4(1):O24. doi:10.1186/1757-1146-4-S1-O24

2.

Vella L, Gatt A, Formosa C. Does Baseline Hemoglobin A1c Level Predict Diabetic Foot Ulcer Outcome or Wound Healing Time? Journal of the American Podiatric Medical Association. https://www.ncbi.nlm.nih.gov/pubmed/28880596. Published July 2017. Accessed September 28, 2019.

3.

King DE, Mainous AG, Buchanan TA, Pearson WS. C-Reactive Protein and Glycemic Control in Adults With Diabetes. Diabetes Care. https://care.diabetesjournals.org/content/26/5/1535. Published May 1, 2003. Accessed September 28, 2019.
OR25-05 Increased Overall Mortality and Cardiovascular Morbidity in Patients with Adrenal Incidentalomas and Autonomous Cortisol Secretion: Results of the ENS@T NAPACA-Outcome Study
Authors: Deutschbein Timo , Reimondo Giuseppe , Dalmazi Guido Di , Bancos Irina , Falhammar Henrik , Tsagarakis Stylianos , Newell-Price John , Kastelan Darko , Stigliano Antonio , Scaroni Carla Maria , Letizia Claudio , Prete Alessandro , Morelli Valentina , Ivocic Miomira , Kaltsas Grigorios , Pazaitou-Panayiotou Kalliopi , Hanzu Felicia Alexandra , Loli Paola , Yener Abdullah Serkan , Shafigullina Zulfiya , Langton Katharina , Zacharieva Sabina , Kocjan Tomasz , Terzolo Massimo , Fassnacht Martin
Published: May 2020

Objective. Several smaller studies on adrenal incidentalomas (AI) suggested an association between autonomous cortisol secretion (ACS) and mortality (Di Dalmazi Lancet Diabetes Endocrinol 2014, Debono J Clin Endocrinol Metab 2014, Patrova Endocrine 2017). However, a recent meta-analysis (9 studies, 1356 patients) could not confirm these findings (Elhassan Ann Intern Med 2019). Aim. To investigate the effects of ACS on mortality, prevalence of cardiovascular (CV) risk factors, and (CV) morbidity, in a representative cohort of AI. Design. Retrospective observational study conducted at 27 ENS@T centers from 15 countries. Methods. Inclusion criteria: AI diagnosed 1996-2015, 1 mg dexamethasone suppression test, follow-up (FU) of ≥36 months, known survival status. Exclusion criteria: clinically relevant adrenal hormone excess (i.e. Cushing’s syndrome, pheochromocytoma, primary hyperaldosteronism), known malignancy. Patient stratification: serum cortisol after dexamethasone (>5 µg/dl, ACS; 1.9-5 µg/dl, possible ACS (PACS); ≤1.8 µg/dl, non-functioning adenoma (NFA)). Definition of CV events (CVE): hospitalization due to myocardial infarction and related interventions (PTCA, surgical bypass), stroke, deep vein thrombosis, pulmonary embolism. Results. 3640 patients (57% NFA, 36% PACS, 7% ACS) were considered eligible: 64% females; median age 61 years (range 18-91); median FU 84 months (36-277) (distribution between subgroups n.s.). 352 patients died during FU. Age- and sex adjusted overall survival was significantly reduced in patients with PACS (HR 1.55; 95%CI 1.24-1.94) and ACS (1.84; 1.29-2.61). Prevalence of CV risk factors were significantly higher in PACS and ACS than in NFA (hypertension: 72, 73, 57%, p<0.0001; dyslipidemia: 42, 49, 35%, p<0.0001; diabetes: 22, 25, 17%, p<0.0001) When adjusted to relevant confounders (i.e. age, sex, CV risk factors), time to first CVE was shorter in PACS (HR 1.36; 1.07-1.73) and ACS (HR 1.62; 1.10-2.40) compared to NFA. Conclusion. PACS and ACS are associated with increased overall mortality and CV morbidity. However, to prove causality a large randomized intervention trial is required.
SUN-699 Canagliflozin Induced Severe Hyponatremia- a Rare Life Threatening and Poorly Understood Complication- a Case Report
Authors: Dhanasekaran Maheswaran , Mehta Suchita
Published: May 2020

Background: Sodium-glucose cotransporter-2 (SGLT2) inhibitors induce osmotic diuresis by inhibiting the proximal renal tubular reabsorption of the filtered glucose load. This can occasionally lead to severe dehydration, hypotension and in some cases, severe hyponatremia. The effects of SGLT2 inhibitors on sodium and water handling by the renal tubules is not well studied.

Clinical Case: A 49-year-old male with history of type 2 diabetes mellitus on canagliflozin, an SGLT2 inhibitor, who was brought to the Emergency Room following a motor vehicle accident from acute onset of confusion and altered mental status. Initial trauma workup was negative. He was found to have severe hyponatremia to 118 mEq/ L (n 135–145 mEq/ L) and was also noted to be in euglycemic ketoacidosis with positive serum ketones (qualitative assessment) along with acute onset urinary retention. Urine toxicology was negative including negative blood alcohol level. Thyroid function was normal 1.080 mIU/ L (n 0.47- 6.90mIU/L). His total urine osmolar excretion was ~ 2400 mOsm in 12h (n 500–800 mOsm/kg of water/ 24 hours), confirming the diagnosis of his ongoing massive osmotic diuresis. On admission, his antidiuretic hormone (ADH) level was noted to be elevated to 9.1 pg/mL (n <4.3pg/ mL). This severe degree of hyponatremia was postulated to be secondary to canagliflozin causing massive osmotic diuresis resulting in severe intravascular volume depletion with reflex increase in antidiuretic hormone (ADH) compounded by increased free water intake by the patient.

Conclusion: With more widespread use of this relatively new hypoglycemic medication with protective metabolic and cardiovascular benefits that include weight loss and reduction of BP in T2DM patients, it is equally important to understand the physiology of potentially life-threatening adverse effects associated with severe volume depletion by massive osmotic diuresis and electrolyte abnormalities that include hypernatremia (even hyponatremia), and the timely recognition of euglycemic ketoacidosis.
SAT-011 Prevalence of Menstrual Disorders and Hormonal Control Use in Elite Female Athletes in New Zealand
Authors: Heather Alison K , Ogilvie Megan , Beable Sarah , Coleman Lynne , Thorpe Holly , Schofield Katie , Sims Stacy , Milsom Stella Ruth , Hamilton Bruce
Published: May 2020

Menstrual disorders are frequent in female athletes, especially those participating at the elite level. Factors which may contribute to impaired ovarian function in athletes include high training volumes, eating disorders and/or low body weight, which in turn may interrupt GnRH signaling. Hormonal contraception may disguise underlying menstrual disorders, and athlete use of such approaches is common, despite limited data on whether hormonal control has positive, neutral or negative effects on athletic performance. To determine the prevalence of hormonal contraceptive use, as well as the prevalence of menstrual disorders, in New Zealand elite female athletes, we completed a national internet-based survey of 219 participants being supported by High Performance Sport New Zealand. The survey aimed to characterize the demographics, health and athletic performance history, the training load and contraceptive use. We found that athletes were training intensely, with 38% reporting training volumes of >70 hours/month. At the youngest age represented (15-19 years), 72% had been in competitive sports for more than 5 years, suggesting a young gynecological age is represented by the cohort. More than half (58%, 127/219) of the surveyed athletes reported diagnosed illness or injuries. Stress fractures (39% 50/127), concussion (31%, 39/127) and asthma (26%, 33/127) were the most common diagnoses, followed by oligo/amenorrhea (20%, 26/127), reduced energy deficit syndrome (9%, 17/194), endometriosis (8%, 16/194), and polycystic ovary syndrome (5%, 9/194). Oligomenorrhea was significantly associated with stress fracture (p=0.018) and disordered eating (p=0.009). More than 50% of athletes tracked their menstrual cycle, and self-reporting showed even higher rates of oligo/amenorrhea 37% (29/79) in athletes not using hormonal contraception. Self-reporting also indicated a high prevalence of other menstrual disorders including delayed menarche (21%,43/207), menorrhagia (30%, 60/203), and dysmenorrhea (32%, 66/203). In athletes reporting menorrhagia, there was a significant association with iron deficiency (p=0.026). Of the 219 athletes, 37% were currently using hormonal contraception, of which the oral combined pill was the most popular (64%). The most commonly cited reason for hormonal contraception was birth control, however athletes used hormonal control to manipulate either the frequency (38%) or the symptoms (29%) of menstruation, particularly around competition. The data clearly suggests that there is likely to be significant undiagnosed gynecological pathology in elite female athletes. Hormonal contraception can mask gynecological health issues and themselves can lead to side effects that affect performance. It remains that health issues, especially those related to gynecological health, need to be considered by athletes, their coaches and medical support staff.
MON-026 Estradiol Triggering Extracellular Matrix Degradation Leading Signalling Cascades Succeeding a Feedback Loop as Contributing Factor to Develop Endometriosis in Females of Reproductive Age
Authors: Malik Arif , Qamar Iram , Waquar Sulayman
Published: May 2020

INTRODUCTION: Endometriosis is common gynaecological disorder that leads to infertility in females of reproductive age. It is characterized by endometrial glands and stromal tissues outside the wall of uterus. Upregulation of estradiol is responsible for the cell proliferation, adhesion and invasion in endometriosis. It enhances prostaglandins (PGE-2) that triggers the formation of matrix metalloproteinases (MMPs), Tumor necrosis factor-α (TNF-α) and nuclear factor kappa B (NF-kB). Whereas, levels of progesterone are reported to be decreased in the patients with endometriosis. Less production of progesterone activity of 17β-hydroxysteroid dehydrogenase-II (17β-HSD-II) decreases that converts estradiol to less potent estrone. Intake of excess trans-fats and deficiency of vitamin D raises level of arachidonic acid and converts PGE-2 by the action cyclooxygenase (COX-2). PGE2 in theca cells of ovaries increases cAMP and activity of liver receptor homologue-1/steroidogenic factor-1(LRH-1/SF-1) thus leading to the stimulation of aromatase enzyme. MATERIALS AND METHODS: Two hundred eighty-eight (n=288) females with endometriosis and hundred (n=100) controls were enrolled. Informed consent was obtained before the collection of samples. Levels of estradiol, progesterone, aromatase enzymes, 17β-HSD-II, COX-2, PGE-2, MMPs (2, 7, 9), vitamin D and lipopolysaccharides (LPO) were estimated by respective protocols. RESULTS: Findings suggests significant increase in the levels of estradiol, aromatase enzymes, COX-2, PGE-2, MMPs (2,7,9) and LPO (67.08±5.55 pg/ml, 7.16±1.28 ng/ml, 1.56±0.144 ng/ml, 4.89±0.61 pg/ml, 995.2±8.15 ng/ml, 105.2±7.19 ng/ml, 109.2±12.25 ng/ml and 125.25±11.26 pg/ml) in patients as compared to (21.08±3.65 pg/ml, 2.08±0.15 ng/ml, 0.61±0.056 ng/ml, 1.158±0.18 pg/ml, 388.26±14.26 ng/ml, 66.29±5.26 ng/ml, 38.29±15.2 ng/ml and 17.25±1.26 pg/ml) controls respectively. Whereas, levels of progesterone, 17β-HSD-II and vitamin D remained significantly low in the endometrial patients (3.07±1.08 ng/ml, 0.183±0.024 ng/ml and 17.17±2.3 ng/ml) as compared to healthy females (29.22±3.29 ng/ml, 1.43±0.153 ng/ml and 36.26±3.09 ng/ml). CONCLUSION: Current study suggests the role of estradiol in triggering ECM degradation and initiating signalling cascades that following a feedback loop enhances the levels of estradiol and contributes in the development and progression of endometriosis. Hence, therapies with supplementation of vitamin D and progesterone may help in regressing the role estradiol and other contributing factors that are involved in the development and progression of endometriosis in the patients. Keyword: Endometrial glands, Stromal tissues, Estrogen, Progesterone, Endometriosis, Vitamin D
SAT-454 A Novel Role of Thyroid Hormone Receptor in Synaptic Plasticity in Cerebellar Purkinje Cells
Authors: Ninomiya Ayane , Hosoi Nobutake , Kokubo Michifumi , Amano Izuki , Haijima Asahi , Miyazaki Wataru , Hirai Hirokazu , Koibuchi Noriyuki
Published: May 2020

Thyroid hormone (TH) is essential for the development and the maintenance of the brain function. TH action is mediated by TH receptor (TR). TR binds to a specific DNA sequence on TH-target genes and thus functions as a ligand-dependent transcription factor. In thyroid diseases such as congenital hypothyroidism or resistance to TH (RTH), TH-TR binding is dominantly disrupted, leading to the various symptoms such as motor deficits. However, in such cases, all the cells that express TR get affected by the disrupted TR signaling; thus, the specific mechanism has not been cleared. It has been well known that proper motor coordination is deeply related to long term depression (LTD) of synaptic transmission from parallel fiber (PF) to Purkinje cell (PC) in the cerebellum (Ito, 1989). Therefore, we examined the involvement of TR in synaptic plasticity at PF-PC synapses by using transgenic mice (Mf-1 mice) which express dominant-negative TR specifically in PCs. Since Mf-1 display the impairment of motor coordination and motor learning, a decrease in TR signaling in PCs may alter synaptic plasticity and contribute to motor incoordination. A whole-cell patch clamp recording of Mf-1 PCs revealed the inhibition of LTD but instead the induction of long term potentiation (LTP) of the synaptic transmission at PF-PC synapses. This indicates that the intracellular calcium dynamics may be disrupted in Mf-1 PCs since LTD requires a higher elevation of the intracellular calcium concentration in PCs than LTP does. Indeed, single-PC qPCR showed that the mRNA levels of some important molecules for the intracellular calcium dynamics in PCs (SERCA2, IP3R, and P/Q-type calcium channel) are downregulated in Mf-1 PCs. This result suggests those genes as possible TH-target genes. Taken together, the present study suggested a novel possible role of TR in synaptic plasticity at PF-PC synapses by regulating the expression of some important genes for LTD occurrence in the cerebellum. This finding could give a new insight into the mechanism of motor deficits in thyroid diseases.
SUN-422 Risk Factors Associated with Thyroid Nodules in Type 2 Diabetes
Authors: Gonzales Sonia Gisella Chia , ruiz victor noriega , Pinto Miguel Eduardo , zárate eduardo pretell , Santisteban Segundo Seclen
Published: May 2020

Objective: To determine risk factors associated with the presence of thyroid nodules in patients with type 2 diabetes

Material and methods: A case control prospective study, matched 1:1, according to age, sex and smoking habit was conducted. Patients with type 2 diabetes were recruited from the Endocrinology Service of Cayetano Heredia Hospital, Lima-Perú. Clinical evaluation, laboratory tests and thyroid ultrasound were performed to indentify patients with type 2 diabetes with and without thyroid nodules. The association was evaluated by calculating Odds ratios (OR) by conditional multivariate logistic regression techniques.

Results: 83 patients with type 2 diabetes and thyroid nodule and 83 patients with type 2 diabetes without thyroid nodule; were obtained. The risk factors associated with the presence of thyroid nodules in patients with type 2 diabetes were HbA1c (OR= 4.12, P= 0.002), BMI (OR= 1.13, P 0.030) and TSH (OR= 3.27, P= 0.0001), with cut-off points according to ROC curve of HbA1c ≥ 8%, TSH in the normal upper limit ≥ 2.3 μIU / mL and BMI ≥ 27 kg / m2. Patients with type 2 diabetes and thyroid nodule had higher values of blood glucose, thyroid volume, abdominal and neck circumference; greater frequency of acantosis nigricans and acrochordons compared to controls.

Conclusions: The risk factors associated with the presence of thyroid nodules in patients with type 2 diabetes were HbA1c, BMI and TSH, with cut-off points according to ROC curve of HbA1c ≥ 8%, TSH in the normal upper limit ≥ 2.3 μIU / mL and BMI ≥ 27 kg / m2.
MON-080 Unusual Association Between Congenital Hyperinsulinism and Neurofibromatosis Type 1
Authors: Marinescu Andreea S , Suarez Elizabeth A
Published: May 2020

Background: Neurofibromatosis type 1 (NF1) is an autosomal dominant multisystemic disorder characterized by an increased risk of benign and malignant tumor formation affecting skin, bone and nervous system. In children with NF1, endocrine manifestations include central precocious puberty, growth hormone deficiency and growth hormone hypersecretion, resulting from complications of optic pathway gliomas involving the hypothalamic and sellar region. A few reports of adults with NF1 have been described to have hypoglycemia due to insulinoma. However, hypoglycemia due to hyperinsulinism has not been described in children with NF1. We present a case of NF1 diagnosed during neonatal period associated with congenital hyperinsulinism.

Case: Patient was delivered at 36 weeks by C- section with birthweight of 2780 grams which was appropriate for her gestational age. There was no maternal history of diabetes. Pertinent exam findings included microcephaly and multiple café-au-lait spots. She developed hypoglycemia at DOL1 with blood glucose of 26 mg/dl which normalized with IV dextrose at a glucose infusion rate of 6 mg/kg/min. At DOL8, an attempt to wean IV dextrose failed and she developed hypoglycemia with blood glucose of 47 mg/dl. Critical sample showed insulin level 3.3 uU/ml, betahydroxybutyrate 0.08 mg/dl (0.2-2.8), cortisol 18.1 mcg/dL and GH 13.2 ng/mL. A glucagon stimulation test showed an increase in glucose of 30 mg/dl. She was diagnosed with hyperinsulinism and started on Diazoxide (8 mg/kg/day) with improvement of blood glucose with prefeed glucose of > 70 mg/dl. She had normal 8- hour fasting tolerance with all BG > 70 while on Diazoxide. Genetic test for known mutations causing hyperinsulinism was negative. Microarray confirmed a 1.42Mb interstitial deletion at chromosome 17q11.2 which encompasses NF1 gene confirming the diagnosis of NF1. Additionally, she has an Xp22.33 duplication of uncertain clinical significance.

Conclusion: Our patient presented with an unusual association between congenital hyperinsulinism and NF1. Further testing needs to be performed to determine whether this association is coincidental or whether congenital hyperinsulinism is a rare manifestation of NF1.
OR21-02 Impact of Nodule Size on the Probability of Hurthle Cell Carcinoma and Other Cancers in Thyroid Nodules with Multiple Chromosomal Copy Number Alterations
Authors: Nikiforova Marina N , Nikitski Alyaksandr , Tebbets Jessica , Tolino Lindsey , Manroa Pooja , Yip Linwah , Nikiforov Yuri E
Published: May 2020

Fine-needle aspiration (FNA) of thyroid nodules yields indeterminate cytological diagnosis in ~20% of cases, confounding patient management. This includes Hurthle cell nodules, which typically yield Bethesda IV and III cytology. Chromosomal copy number alterations (CNA) are known to occur in thyroid tumors, particularly in Hurthle cell carcinomas (HCC) as well as in other typically follicular-patterned tumors including papillary thyroid carcinomas (PTC) and poorly differentiated thyroid carcinomas (PDTC). The aim of this study was to evaluate thyroid nodules tested positive for CNA but negative for all other genomic alterations using ThyroSeq v3 NGS assay in order to establish the probability of cancer in these nodules and find whether it is influenced by the pattern of CNA and nodule size. We evaluated 111 nodules with multiple CNA detected by ThyroSeq in FNA samples and available surgical pathology outcome. Of those, 69 (62%) nodules showed CNA changes consistent with genome near-haploidization (GNH) whereas 42 (38%) nodules had multiple chromosomal losses and gains (CLG). Nodule size ranged from 0.5-10.2 cm; cytology was Bethesda III in 54%, Bethesda IV in 43%, and Bethesda V-VI in 3% of cases, with Hurthle cells mentioned in the cytology report in 64% of cases. On surgical pathology, 38 (34%) of these nodules were malignant (including 24 HCC, 8 PTC, and 5 oncocytic PDTC) and 73 (66%) were benign (including 43 Hurthle cell and 18 follicular adenomas). No significant difference was observed in probability of malignancy between the two patterns of CNA (p=0.41). However, a significant correlation between the nodule size and probability of cancer was found (p=0.006). In specific CNA groups, correlation between cancer and nodule size remained significant for nodules with GNH pattern (P=0.0002), but not with CLG pattern (p=0.449). Specifically, cancer probability in nodules with GNH pattern and <2 cm in size was 14% (all cancers minimally-invasive), 2.0-2.9 cm was 33%, 3.0-3.9 cm was 50%, 4-4.9 cm was 67%, and ≥5 cm was 80%. Among high-risk cancers (widely-invasive or angioinvasive HCC, PDTC), all 10 tumors had the GNH pattern (p=0.01) and average nodule size of 4.9 cm (range, 2.1-8.5 cm). These findings suggest that CNA of both types are frequently found in Hurthle cell tumors, and probability of cancer in nodules with CNA and no other mutations increases with larger nodule size. This may help to refine the pre-operative assessment of cancer probability and risk of more aggressive disease and offer more tailored management to these patients.
SUN-689 Treatment of Hepatitis C Has Time-Dependent Relationship with Type 2 Diabetes Progress
Authors: Liu Luna , Ding Yi , Liu Hong-Biao
Published: May 2020

Introduction

Hepatitis C virus (HCV) is not only related to hepatic impairment but also associated with metabolic complications, such as glucose intolerance and lipid dis-regulation. In addition, HCV can affect pancreatic Beta-cells function. There are multiple controversial reports regarding the relationship between antiviral treatment and diabetes mellitus (DM) development. We performed continuous observation of a long-term nursing home facility DM patient treated with HCV.

Case Presentation

52 y/o white male nursing home patient history of hepatitis C and type 2 diabetes mellitus was treated with ledipasvir/sofosbuvir (90 mg - 400 mg) for 12 weeks. Prior to HCV treatment patient DM control was treated with oral medications (metformin and glipizide) with fast glucose level fluctuating 143±44 mg/dl; 2 hours postprandial level 205±57mg/dl; HbA1c 7.0%. There was no significant change of finger sticks during the 12 weeks of HCV treatment fast glucose 121 ±27 mg/dl and 2 hours postprandial level 176±62 mg/dl.DM management remained the same treatment plan. In the first three months after HCV treatment course patient DM was progressively getting worse with fast glucose level 221±56mg/dl; 2 hours postprandial levels 300±71 mg/dl. HbA1c 8.7% (3 months after HCV treatment). Oral DM medications were doubled dosages and maximum dosage of pioglitazone was added on. In addition, insulin sliding scale and long acting insulin accumulated daily dosage around 120 units. Starting from four months after HCV treatment patient DM was gradually improving evidenced by fast glucose levels 92±10mg/dl and 2 hours postprandial levels 117±30 mg/dl; HbA1c 5.6% with the same management strategies. Seven months after HCV treatment patient DM was stable with fast glucose levels 91±8 mg/dl and 2 hours postprandial levels 115±29 mg/dl; HbA1c 4.8% and insulin sliding scale and glipizide were discontinued. Long acting insulin dosage was decreased to 74 units daily. Eighteen months after HCV treatment patient fast glucose levels and 2 hours postprandial levels were in normal range and HbA1c 5.6%.

Discussion

Based on our observation there are four phases of DM development related to the HCV treatment: phase I silence stage (during 3 month HCV treatment) DM is stable; phase II deterioration stage (First 3 month after HCV treatment) DM is progressively getting worse; phase III recovery stage (4 to 6 month after HCV treatment) DM is gradually improving; phase IV stabilization stage (6 month after HCV treatment) DM is stabilized and improved.

Conclusion

Anti-viral treatment of HCV has possible intrinsic time-dependent relationship with DM development.
SAT-515 Anorexia and Severe Hypothyroidism Driving Persistent Ascites and Liver Injury
Authors: Gugger Aristea Sideri , Viana Gracia , Stamatiades George Alexiades , Majumdar Sachin K
Published: May 2020

Background Unintentional weight loss, ascites, and altered mental status typically raise concerns for hepatologic-cardiac-oncologic disease. Herein we present a case that after exhaustive workup the etiology of the aforementioned findings was attributed to a combination of anorexia and severe hypothyroidism, states where slowed metabolism and altered nutritional status can interact synergistically. Clinical Case A 71 y/o lady with a history of hypothyroidism after RAI for Graves’ disease, anxiety, depression, presented with 20-30 lbs unintentional weight loss over 5 months. She had poor appetite, nausea, constipation, increased abdominal girth, anasarca, fatigue, weakness, and altered mental status. On exam she had bradycardia, hypotension and hypothermia (BP 97/51, HR 54, RR 18, Temp 94, BMI 15.8). Labs revealed a TSH of 36, FT4 0.98, Tbili 0.3, alk phos 491, AST 435, ALT 651, gGT 151, albumin 2.3, prealbumin 14.7, INR 1.03, and pancytopenia. Treatment with IV levothyroxine resulted in mental status improvement. Over the next few months extensive testing revealed mild element deficiencies (zinc 44- nl range 60 - 130 mcg/dL, vit A 32- nl range 38 - 98 mcg/dL), no evident infectious/hematologic or inflammatory disease. Despite 3 paracenteses, 2 liver biopsies, multiple imaging studies (abdominal U/S, ECHO, XRs, CT chest/abdomen/pelvis, MRI abdomen/pelvis, enterography, MRI brain, PET scan), EGD/colonoscopy, bone marrow bx, and explorative laparoscopic abdominal surgery, no clear explanation was found. During the workup her liver enzymes remained elevated, TSH and fT4 normalized, but T3 remained low at 50 (76 - 181 ng/dL). Psychiatric evaluation revealed mild cognitive impairment, presumed to be secondary to depression and underlying disease. By exclusion, she was diagnosed with anorexia with a possible component of persistent hypothyroidism. She was fed through NG tube and followed closely by nutrition with a personalized high protein and calorie meal plan. Eight months later she had gained 5 lbs, her liver enzymes/electrolytes and CBC normalized, and most of her symptoms resolved. Conclusion Hypothyroidism can cause LFT abnormalities, and though rare, there are >50 cases of hypothyroidism induced ascites reported. Usually LFTs and ascites normalize promptly with hormone supplementation. However, our patient’s case was complicated by severe anorexia, with nutritional status essentially equivalent to kwashiorkor sufferers. Though extremely rare in the developed world and in adults, kwashiorkor like physiology has been described in patients with anorexia, with impressive liver abnormalities, presumed to be due to autophagy. Though certainly this is a rare diagnosis, it does point to the fact that in our test driven culture, it is worth pausing, re-evaluating history and physical and thinking outside the box prior to subjecting our patients to countless tests and procedures.
MON-072 A 2 -Year Old Girl with Turner Syndrome and Neurofibromatosis Type 1
Authors: Dermitzaki Eleni , Manolakos Emmanouil , Tagalakis Panagiotis , Kleanthous Kleanthis , Papadimitriou Dimitrios T
Published: May 2020

Introduction: Turner syndrome (TS) occurs due to loss of either all or part of the X chromosome, in some or all the cells of the body. The most consistent features of TS are short stature and premature ovarian failure. Neurofibromatosis type 1 (NF1) is an inheritable in an autosomal dominant manner tumor predisposition syndrome and is caused by loss-of-function mutations in the tumor suppressor NF1 gene (neurofibromin 1). Literature review indicated rare cases with NF1 and TS (1). We report the sixth girl with mosaic TS and NF1 who presented with optic nerve glioma.

Case report: A 2-year-old female presented to us due to short stature. Her height was 2,5 SD lower than the mean parental height curve, and her bone age was delayed only by 3 months. She already had a normal (46XX) peripheral blood karyotype (70 mitoses). She had abnormal body proportions and with short limbs with unremarkable café au lait spots. Additionally, to the short stature laboratory investigation we ordered a gene panel to exclude hypochondroplasia, and a Karyotype in fibroblasts culture from oral cavity sample. The results revealed low IGF-1 and mosaic TS in 14%. We preformed 2 provocative tests which revealed low growth hormone peak < 5 ng/ml. A brain and pituitary MRI to exclude pituitary lesions or structural abnormalities revealed gliomas of the optic chiasma and the right optic nerve with characteristic NF1 “spots” (regions of signal abnormality in T2 sequences) involving the basal ganglia, cerebellum and the right temporal lobe. DNA sequencing targeted to a gene panel related to NF1 and NF2 revealed a novel de novo heterozygous NF1 gene mutation in exon 28 [3764Α>G];[=]p.[Gln1255Arg].

Discussion: NF1- Gliomas are most commonly seen in young children, (mean 4.5 years). Only 1/3 of affected children will require therapeutic intervention. However early diagnosis, of optic gliomas is important. Our patient was completely asymptomatic by the time of diagnosis and no other symptom or sign of NF1 was apparent. Ophthalmologic examination was normal, but visual electrophysiologic testing was abnormal as far the right optic nerve is concerned. The oncology team decided to preform chemotherapy. In TS impaired growth is related to resistance in GH. Some studies suggested that there could be a relationship between GHD and NF1 even in the absence of an organic pituitary damage. In our patient it has been decided not to treat with GH and closely track the patient’s growth.

Conclusion: Coexistence of NF1 with TS is rare. Awareness is needed as early identification and treatment of CNS gliomas can prevent visual loss and severe co-morbidities.

1.

Rare Presentation of Neurofibromatosis and Turner Syndrome in a Pediatric Patient. Pediatr Rep. 2017 Jun 26; 9(2): 6810
SAT-639 Is the Freestyle Libre Flash Glucose Monitor Accurate in the Critically Ill?
Authors: Johnson-Rabbett Brianna , Hashmi Hiba , Lyerla Ryan , Lafave Laura
Published: May 2020

The FreeStyle Libre flash glucose monitor (FGM) has made the use of continuous glucose monitors more accessible to the typical diabetes patient in an outpatient setting given the significantly lower cost and ease of use of FGM as compared to other systems. However, FGM is not labeled for use in a critically ill population. The critical care department at our institution queried the endocrine department about studying the use of FGM in critically ill patients. The interest of the critical care department was due to the potential of decrease in patient discomfort and decrease in time and effort of nursing and support staff related to the performance of fingerstick capillary glucoses if FGM was an adequate replacement measure.

As of yet, there has been only minimal study of flash glucose monitoring in critically ill patients. One Australian study evaluated 8 patients in an ICU setting and determined that as compared with arterial blood glucose monitoring, flash glucose monitoring provided acceptable numerical and clinical accuracy.1 A Swedish study evaluated a total of 26 patients undergoing cardiac surgery and compared the use of FGM to use of a microdialysis intravascular system and concluded that the microdialysis system was more accurate, though in this study, only 25% of patients had diabetes. 2

To further investigate use of FGM in a critically ill population, we plan to undertake a single center, prospective, single arm study enrolling at least 20 and up to 40 patients. Inclusion criteria include a known diagnosis of type 1 or type 2 diabetes, age of 18 or older, and admission to the medical intensive care unit (MICU) with expected MICU stay of at least 48 hours.

Participating subjects will have a sensor applied by a study investigator. After confirmation that the sensor is operational, the investigator will place opaque tape over the monitor to blind the monitor data. Nurses or medical assistants will conduct the standard of care fingerstick glucose monitoring per hospital protocol but will also have been notified of request to also pass FGM reader over the sensor at time of fingerstick glucose data collection.

The primary objectives are to determine numerical accuracy in a critical care setting using the mean absolute relative difference and to determine clinical accuracy in a critical care setting using the surveillance error grid and the clarke error grid analyses. Preliminary data should be available by March, 2020.

1.

Ancona P, Eastwood GM, Lucchetta L, Ekinci EI, Bellomo R, Martensson J. The performance of flash glucose monitoring in critically ill patients with diabetes. Crit Care Resusc 2017; 19: 167-174, June 2017.

2.

Schierenbeck F, Franco-Cereceda A, Liska J. Accuracy of 2 Different Continuous Glucose Monitoring Systems in Patients Undergoing Cardiac Surgery: Intravascular Microdialysis Versus Subcutaneous Tissue Monitoring. Journal of Diabetes Science and Technology 2017, Vol. 11(1) 108–116
SAT-126 Breast Adipose Tissue Extracellular Vesicles from Obese Women Increase Breast Cancer Aggressiveness - a Novel Mechanism for the Obesity-Breast Cancer Link
Authors: Benito-Martin Alberto , Paik Paul , Mushannen Malik , Bhardwaj Priya , Oshchepkova Sonya , Spector Jason , Brown Kristy A
Published: May 2020

Background and Objectives: Breast cancer is among the most common cancer in women with 2.1 million new cases detected each year. Numerous studies have demonstrated a connection between body mass index (BMI) and cancer incidence, with obesity (BMI ≥ 30) being responsible for the development of at least 13 types of cancer, and 15% to 20% of total cancer-related mortality. The effects of extracellular vesicles (EVs) derived from the obese adipose tissue microenvironment on breast cancer have not yet been clearly elucidated.

Methods: EVs were obtained from media conditioned with human breast adipose tissue from reduction mammoplasty (n=31). Women were healthy at the time of surgery and had no history of breast cancer. Patient samples were stratified based on their body mass index (BMI), with a BMI < 25 considered healthy and a BMI ≥ 25 considered overweight/obese. Breast adipose tissue-derived EVs (AT-EVs) were characterized (Quantitative Mass Spectrometry) and used to treat human breast cancer cell lines, including the ER+ MCF7 and triple negative breast cancer (TNBC) MDA-MB-231. Effects on cell proliferation and migration in vitro, and on tumor growth in a mouse xenograft model, were examined after long-term education with EVs. RNA sequencing was performed to investigate potential reprogramming induced by AT-EVs.

Results: We found a positive correlation between protein amount per AT-EV and BMI. Quantitative proteomics of AT-EVs revealed 46 proteins that were significantly higher and 54 proteins that were significantly lower in specimens from women with a BMI ≥ 25 compared to women with a BMI < 25. AT-EVs from patients with a BMI ≥ 25 induced proliferation of MCF7 cells compared to AT-EVs from patients with a BMI < 25. Obese EVs induced a more aggressive phenotype in MDA-MB-231 cells, increasing their invasiveness in vitro. Obese EVs also increased the growth of MCF7 and MDA-MB-231 cells in vivo. Ingenuity pathway analysis of RNA-Seq data identified significant differences in mTOR signaling and canonical pathways associated with altered mitochondrial function.

Conclusion: Our studies identify a novel mechanism to explain the obesity-breast cancer link in older women. Namely, that in obesity, the breast microenvironment produces EVs capable of reprogramming breast cancer cells to grow faster and be more aggressive. Identifying which cargo in breast AT-EV mediates these effects may provide new targets for intervention.
SUN-428 Rural India Embracing Advanced Techniques in MIS:- A Series of 20 Cases of Thyroid Surgeries by Transoral Endoscopic Thyroidectomy-Vestibular Approach (TOETVA) Technique with Respect to Acceptance of Progressive Surgeries Using Advanced Technologies, Techniques by Rural Patients and it’s Safety & Feasibility in Small Setup Hospital in Rural India
Authors: Lohokare Narendra Vijay , Velankar Aditi C
Published: May 2020

Aims & Objectives

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) an alternative surgical technique for thyroid surgery is slowly gaining widespread popularity.

Majority of TOETVA surgeries are performed in Tertiary Care institutes. It’s safety & Feasibility in small setup hospitals has not been reported until now. The key challenges in Indian Rural healthcare sector are Lack of Quality Infrastructure, Dearth of qualified medical functionaries and NonAccess to basic medicines and medical facilities thwarts its reach to population in rural India. Indian Health Care sector is a self-pay market. Lack of awareness & affordability being a challenge with patients they remain apprehensive in acceptance of Advanced Technology or newer Techniques.

This series is an attempt to study A shift in acceptance of progressive surgeries using Advanced Technologies & Techniques by Rural Patients and its Safety & Feasibility in Smaller operative setups in rural India.

Methods

Proper patient selection along with proper instrumentation & OT setup helped complete the procedures without any major complication.

Advanced Instrumentation along with essential Operation Theatre setup were utilised for performing Total of 20 TOETVA procedures.

For successful execution of TOETVA surgeries extensive Training Programs were furnished to equip stakeholder teams with respective Skill, Knowledge & Attitude sets.

Organisational SWOT Analysis & Competency mapping contributed to strategise a helping approach to Educate & Influence stakeholders.

Results

Total 20 patients were operated by TransOral Endoscopic Thyroidectomy - Vestibular (TOETVA) Technique from May 2018 till September 2019.

Three SubTotal Thyroidectomies & 16 Hemithyroidectomies were performed. One patient was operated for Thyroglossal cyst.

Increased awareness about a need to Improve on competence of Empathy & Accountability, Pursuit of Quality Care & Inculcating Cost-Effective use of the results of relevant research in regular functions.

Conclusions

There is a noticeable paradigm Shift in acceptance of rural patients as well as of rural paramedical staff that these surgeries which require Advanced Technology & Innovative Techniques are easily Accessible & Executable without undue cost burden with utmost safety at their own vicinity even in the small setup hospitals.

This study aids to recommend Feasibility & Safety of TOETVA even for small setup of hospitals in Rural India.
SAT-644 A Case of the Use of the Eversense Continuous Glucose Monitor with Repeated Same-Pocket Insertion
Authors: Lee Warren , Wright Lorena Alarcon Casas
Published: May 2020

Introduction:The Eversense continuous glucose monitoring (ECGM) system is a 90-day implantable, subcutaneous device approved for patients with diabetes. The manufacturer recommends alternating arms for each subsequent insertion site to allow for appropriate healing. To date, there is few data describing use of the same subcutaneous pocket for all subsequent ECGM devices. We present the experience of a patient’ s first year use of ECGM with 4 out of 5 device placements within the same subcutaneous pocket. The patient uses an insulin pump and is a concomitant user of Dexcom G5 continuous glucose monitor, allowing us to compare data from his two CGM systems.

Clinical Case:42-year-old male with a 14-year history of type 1 diabetes, user of the ECGM from July 2018 to date. The first device was placed in his right arm; his second ECGM was placed in his left arm with all subsequent implant replacements in the same pocket, a total of 5 devices, four in the same pocket. Patient baseline glucometric data obtained from his first ECGM device (period 1 [P1]) indicated an estimated HbA1c (A1c [%]) of 7.06, average glucose (AG [mg/dL]) 156±61, coefficient of variation (CV) 39.1, time in range (TIR [%]) 66.73, time below range (TBR [%]) 2.59, time in serious low (SH [%]) 0.41, time above 180 mg/dL (TA180 [%]) 21.38, and time in serious high, above 250 mg/dL (TA250 [%]) 8.72. Data obtained from subsequent device insertions is described by periods of data time: period 2, 3 and 4 (P2, P3, P4). Glucometric data was as follows for the 3 time periods. A1c was 6.9, 6.9 and 7.1; AG 152±65, 153±64, 157±68; CV 42.7, 41.8, 43.3; TIR 65.7, 65.72, 64; TBR 3.81, 4.13, 3.68; SH 0.93, 0.7, 0.92; TA180 20.1, 20.2, 20.2; TA250 9.3, 9.1, 10.7 respectively for P2, P3 and P4. All four ECGM devices were replaced successfully within the same subcutaneous pocket with minimal bleeding and discomfort. There were no complications, and all devices functioned well, with excellent and constant transmitter signal and longevity. A 1-month overlapping Dexcom CGM data at the end of P2, start of P3 demonstrated A1c of 6.8; AG 144±64; TIR 67.2; TBR 7.5; SH 1.9;TA180 25.3 and TA250 8.2. ECGM data of the same time frame showed A1c of 7.3, TIR of 59.5, TBR 3.6, SH 1.09, TA180 22.1, and TA250 13.5.

Conclusions:Our experience with the ECGM over repeated insertions within the same pocket shows that using this technique is a feasible method for subsequent device implantation. We present one of our patients, user of ECGM, with the longest use of same insertion pocket, demonstrating adequate and constant signal and no complications. The ECGM procedure itself has minimal risk for bleeding, pain, and infection. The use of the same pocket further decreases this risk, by decreasing the number of punctures and procedure time. Consideration for same pocket insertion is proposed to be discussed with the patient, limiting the same pocket insertion to a maximum of one year, based on our clinical experience.