bluuebunny/crossref_metadata_2025 huggingface dataset:
Climate change in Kazakhstan: implications to population health
Authors: Oladejo Toheeb Olalekan , Balogun Fatai Omeiza , Haruna Usman Abubakar , Alaka Hassan Olayemi , Almazan Joseph , Shuaibu Musa Saidu , Adedayo Ibrahim Sheu , Ermakhan Zhanerke , Sarria-Santamerra Antonio , Eliseo Don Lucero-Prisno
Published: October 2023

Background

Globally, climate change is one of the most pressing issues affecting the human race. The health of the Kazakh people is significantly impacted by climate change, which has made Kazakhstan one of the most vulnerable nations in Central Asia. This study reviews the impact of climate change on population health in Kazakhstan and provides recommendations to address these issues.

Main body of the abstract

This review paper evaluated available evidence and resources, which included journal articles, country reports, World Bank reports, United Nations Development Program reports, and other findings and reports relevant to the issues of climate change and the quality of life of the Kazakh people. The impact of climate change on the country is becoming more pronounced. Floods, deterioration of water quality, melting of glaciers, and extremes of temperature are some of the direct impacts of climate change observed in the country. These changes were shown to affect the health of the population.

Short conclusion

This review revealed mounting proof of how climate change is having an increasing impact on the lives of people in Kazakhstan. There is now an urgency to address the impact of climate change by implementing various mitigation and adaptation strategies.
Combining biosignals with RFID to develop a multimodal-shared control interface
Authors: Kumari Preeti , Mathew Lini , Kumar Neelesh
Published: October 2023

The paper presents an approach to develop assistive devices by combining multimodal biosignals and radio frequency identification (RFID). The brain and eye signals have been used as multimodal biosignals to control the movement of a robot in four directions and help reach near the object following a predefined path. RFID shared control over object identification, and the gripper arm connected at the end effector of the robot performs pick and place operations. Horizontal electrooculography (EOG) has been used forx-directional movement control and electroencephalography (EEG) signal obtained by visual stimulus, called steady-state visual-evoked potential (SSVEP) has been used fory-directional movement control of a robot. The SSVEP signal has also been used to ring an alarm in case of an emergency call by the user. Two parameters classification accuracy (CA) and information transfer rate (ITR) have been calculated for the performance evaluation of the proposed multimodal-shared control model and have shown improved results as compared to previous literature. The results also proved that the proposed model can be used for real-time mobility assistive applications.
Patritumab Deruxtecan (HER3-DXd), a Human Epidermal Growth Factor Receptor 3–Directed Antibody-Drug Conjugate, in Patients With Previously Treated Human Epidermal Growth Factor Receptor 3–Expressing Metastatic Breast Cancer: A Multicenter, Phase I/II Trial
Authors: Krop Ian E. , Masuda Norikazu , Mukohara Toru , Takahashi Shunji , Nakayama Takahiro , Inoue Kenichi , Iwata Hiroji , Yamamoto Yutaka , Alvarez Ricardo H. , Toyama Tatsuya , Takahashi Masato , Osaki Akihiko , Saji Shigehira , Sagara Yasuaki , O'Shaughnessy Joyce , Ohwada Shoichi , Koyama Kumiko , Inoue Tatsuya , Li Li , Patel Parul , Mostillo Joseph , Tanaka Yoshimi , Sternberg David W. , Sellami Dalila , Yonemori Kan
Published: October 2023

PURPOSE

Human epidermal growth factor receptor 3 (HER3) is broadly expressed in breast cancer; high expression is associated with an adverse prognosis. Patritumab deruxtecan (HER3-DXd) is an investigational HER3-targeted antibody-drug conjugate that is being evaluated as a novel treatment in HER3-expressing advanced breast cancer in the U31402-A-J101 study.

METHODS

Adults with disease progression on previous therapies were eligible. Patients in the dose-escalation, dose-finding, and dose-expansion parts received HER3-DXd 1.6-8.0 mg/kg intravenously once every 3 weeks or one of two alternative dosing regimens. In the dose-escalation part, the primary objectives were to determine the maximum tolerated dose and recommended dose for expansion (RDE). The safety and efficacy of the RDE were assessed during dose expansion.

RESULTS

One hundred eighty-two enrolled patients received ≥1 dose of HER3-DXd. Patients had a median of five previous therapies for advanced disease. Efficacy results are reported across clinical subtypes: hormone receptor–positive (HR+)/human epidermal growth factor receptor 2–negative (HER2-negative) breast cancer (n = 113; objective response rate [ORR], 30.1%; median progression-free survival [mPFS], 7.4 months), triple-negative breast cancer (n = 53; ORR, 22.6%; mPFS, 5.5 months), and HER2-positive breast cancer (n = 14; ORR, 42.9%; mPFS, 11.0 months). Objective responses were observed in cancers with HER3-high and HER3-low membrane expression. Dose-limiting toxicities observed during dose selection were decreased platelet count and elevated aminotransferases. In dose expansion, GI and hematologic toxicities were the most common treatment-emergent adverse events (TEAEs) observed. Grade ≥3 TEAEs were observed in 71.4% of patients, and 9.9% discontinued treatment because of TEAEs. Three grade 3 and one grade 5 treatment-related interstitial lung disease events occurred.

CONCLUSION

HER3-DXd demonstrated a manageable safety profile and durable efficacy in heavily pretreated patients across clinical subtypes. These data warrant further evaluation of HER3-DXd in patients with HER3-expressing metastatic breast cancer.
FRI499 The Importance Of Identifying Atypical Presentation Of Thyroid Storm
Authors: Hernan Sacoto Daniel , Alejandra Villavicencio Camila , Franco-Akel Alberto , Belokovskaya Regina
Published: October 2023

Disclosure: D.H. Sacoto: None. C.A. Villavicencio: None. A. Franco-Akel, MD: None. R. Belokovskaya: None.

Thyroid storm is a rare and life-threatening syndrome. Despite treatment and supportive measures, it has an estimated mortality around 8–25%. Identifying atypical clinical presentation such as psychosis is crucial since prompt diagnosis and treatment is paramount for survival. We present an unusual case of psychosis as the manifesting symptom of thyroid storm.A 54-year-old female with a history of major depressive disorder, hypertension, and Graves’ disease presented to the ED with a 3-day history of bizarre behavior noted by the family. At the time of examination, the patient had pressured and circumferential speech, flight of ideas, labile mood, and paranoid ideations. On further questioning, patient reported palpitations and lack of sleep on days previous to presentation. Vital signs revealed hypertension (182/101 mmHg), tachycardia (176 beat per minute), tachypnea, and a temperature of 99.6 °F. Warm skin, fine tremors, and patellar hyperreflexia were noted on physical examination. Subsequent studies showed a suppressed TSH (<0.01uIU/mL), an elevated T3 (227ng/dL) and free T4 (2.1ng/dL). TSH receptor antibody was found positive. Patient’s clinical presentation combined with a Burch-Wartovsky scale of 55 stablished the diagnosis. Further history was notable for non-adherence to methimazole. Iodine-131 was administered. Further treatment with prednisone, propranolol, and cholestyramine was started. Patient showed subsequent clinical improvement. Thyroid storm is a rare complication of hyperthyroidism. It is commonly precipitated by infection, surgery, or medication non-adherence. Atypical presentation of thyroid storm can be disguised as psychiatric condition or substance abuse disorder. These manifestations can be the result of a generalized hypermetabolism generated by an increase in NA+/K+ ATPAse activity, raising the basal metabolism, resulting in thermogenesis. In addition, upregulation of beta-adrenergic receptors lead to increased central nervous system sympathetic response. This results in a catecholamine surge which may manifest as psychosis, mania, or coma. Being aware of atypical presentation in thyroid storm such as active psychosis is key in early diagnosis and prompt management.

Presentation: Friday, June 16, 2023
FRI507 Thyrotoxic Periodic Paralysis: A Rare Occurrence Of Exogenous Thyroid Replacement
Authors: Case James , Suravajjala Devi , Eranki Vijay
Published: October 2023

Disclosure: J. Case: None. D. Suravajjala: None. V. Eranki: None.

Thyrotoxic periodic paralysis (TPP) occurs suddenly through excess thyroxine in tandem with insulin spurring an intracellular shift of potassium via increased activity of Na+/K+ ATPase pump leading to depletion of extracellular potassium with subsequent destabilization of cellular membranes and ensuing paralysis presenting with proximal muscle weakness of the legs. Common triggers involve vigorous exercise, infection, carbohydrate-rich meals, thyroiditis and graves' disease. Patients may be treated with IV potassium, non-selective beta blockers and treating the underlying cause. Exogenous thyroid hormone replacement causing iatrogenic hyperthyroidism as a cause of TPP is very rare. We present one such case below. A 61-year-old male with a history of primary hypothyroidism on thyroid replacement, atrial fibrillation, diabetes mellitus and hypertension, was admitted in September 2019 for lower extremity weakness at which time he was found with hypokalemia; he symptomatically improved following potassium replacement. He had a similar hospitalization in October, 2022 at which time he was found to have weakness alongside hypokalemia and hypomagnesemia, both of which were replaced with symptomatic improvement. He presented as an outpatient for follow up with likely etiology being TPP. Upon further review he had been taking both LT4 (Synthroid) 75mcg daily and T4/T3(Armour) 60mg daily; of note his TSH had been suppressed since 2019, three years prior to presentation. He was unsure why he had been on combination therapy. At our initial visit his labs were: TSH <0.005mIU/mL, free T4 1.38 ng/dL and T3 199 ng/dL. He was advised to stop all thyroid hormone replacement and experienced symptomatic improvement with normalization of potassium and magnesium. Repeat TFTs are pending for appropriate replacement dosing. Recognition of TPP and distinguishing from other etiologies of lower extremity weakness as well as other forms of periodic paralysis would aid in early resolution of an easily treatable, yet severe, condition given the implications of prolonged hypokalemia; earlier recognition of TPP in this patient as a sign of thyrotoxicosis may have prevented later hospitalizations and reduced risk of development of atrial fibrillation. This case also demonstrates the need for adequate monitoring and dosing of thyroid hormone supplement as well as potential complexities and risks of combination therapy in preventing an exogenously induced thyrotoxic state.

Presentation: Friday, June 16, 2023
FRI508 A Case Of Durvalumab Induced Hypothyroidism
Authors: Cecilio La Riva Estefania Del Valle , Acosta Crystal , Manzano Alex J
Published: October 2023

Disclosure: E.D. Cecilio La Riva: None. C. Acosta: None. A.J. Manzano: None.

Background: Immune checkpoint inhibitors (ICIs), like Durvalumab, have become a mainstay in cancer treatment as they have significantly improved survival rates, especially for lung cancer. These treatments, however, have been associated with immune-related adverse events (irAEs) including dermatological manifestations, gastrointestinal symptoms, and endocrinopathies. Clinical Case: A 62-year-old male was diagnosed with a poorly differentiated adenocarcinoma with signet ring cell features stage IIIA of the right upper lobe with concurrent prostate cancer who was initially started on chemotherapy with Cisplatin/Pemetrexed for two months (four cycles) and radiation. He was subsequently started on Durvalumab. Thyroid function tests were performed after starting Durvalumab and TSH was 3.46 mlU/L (reference range: 0.40-4.50), Free T4 was 1.2 ng/dL (reference range: 0.8-1.8) and Free T3 was mildly elevated at 4.3 pg/mL (reference range: 2.3-4.2). The patient remained asymptomatic until about 12 weeks later when he began feeling occasional episodes of anxiety and shortness of breath with fatigue that was brought on at random instances. Thyroid function tests at that time showed an undetectable TSH at <0.01, an elevated free T3 at 4.9, and a normal free T4 at 1.6. Immunotherapy was continued and the patient was referred to endocrinology. Repeat thyroid function tests 8 weeks later showed an elevated TSH at 19.55, decreased free T4 at 0.7, and a normal free T3 at 3.1. The patient was started on levothyroxine at that time with improvement of his symptoms. Upon follow-up 4 weeks later, TSH was found at 30.56 and free T4 at 0.9 which improved with levothyroxine dose adjustment. Conclusion: The case of a patient with thyroiditis beginning as transient hyperthyroidism on Durvalumab is described. Hypothyroidism occurs in about 1.82% of patients on ICIs, with more common occurrences on Nivolumab (51.38%) and Pembrolizumab (24.44%). The incidence of hypothyroidism and thyroiditis on Durvalumab is about 3.11% and 2.04% respectively. Thyroid dysfunction with ICIs occurs with PD-1/PD-L1 blockade and an inflammatory, destructive thyroiditis can be seen. Routine monitoring of thyroid function should be performed before and throughout treatment with an ICIs. Preexisting autoimmune thyroid disease may be a risk factor for developing thyroid disease during treatment, but this has not been well studied. Meta-analysis has shown that preexisting autoimmune disease was a risk factor for irAE incidence. This case highlights the importance of proactive monitoring of thyroid function during treatment.

Presentation: Friday, June 16, 2023
FRI511 Bexarotene: A Deceptive Cause Of Iatrogenic Hypothyroidism
Authors: Ghaith Sarah , Ramachandran Aishwarya , Alcorn Chris , Amer Farah , Thompson Alicia , Ramachandran Akshaya
Published: October 2023

Disclosure: S. Ghaith: None. A. Ramachandran: None. C. Alcorn: None. F. Amer: None. A. Thompson: None. A. Ramachandran: None.

Background: Bexarotene, an antineoplastic agent used for the treatment of cutaneous T cell lymphoma, is associated with a rapid and profound suppression of thyrotropin, which may lead to central hypothyroidism. Case: A Seventy-four-year-old female with a recent diagnosis of Cutaneous T cell lymphoma presented with a 1-week history of progressive fatigue, lightheadedness, and night sweats. She was found to have hypotension and hypothermia. She was started on oral Bexarotene chemotherapy 225 mg daily five days prior to admission. The physical exam was unremarkable except for sinus bradycardia and hypothermia. Labs were significant for TSH 0.48 [0.4-4.2 uIU/mL] dropped from 3.3 uIU/mL one week prior, FT4 0.5 [0.8-1.7 ng/dL] and Total T3 111 ng/dL [87- 187 ng/dL] consistent with central hypothyroidism. Bexarotene was held during her hospitalization per hematology recommendations. The patient was started on Levothyroxine 50 mcg, which was later advanced to 75 mcg daily based on free T4 levels. At one month follow up, free T4 level normalized while on Levothyroxine and Bexarotene was restarted again by her hematologist. Discussion: Bexarotene, an antineoplastic agent approved for treating cutaneous T cell lymphoma, can rapidly suppress TSH levels by directly inhibiting its secretion and affect thyroid hormone metabolism, leading to central hypothyroidism. The degree of suppression of TSH increases with higher doses of Bexarotene while reduction in free T4 and TSH are reversible. Patients already receiving thyroid hormone therapy may require increased thyroid hormone doses to achieve therapeutic levels. If bexarotene is permanently discontinued, levothyroxine can either be stopped or can be resumed to doses used prior to bexarotene therapy. Recovery of thyroid function usually occurs within weeks of Bexarotene discontinuation. Conclusion: Oral Bexarotene can cause central hypothyroidism therefore, thyroid function tests should be measured at baseline and treatment. Thyroid hormone replacement should be considered if central hypothyroidism is suspected.

Presentation: Friday, June 16, 2023
FRI568 Hashimoto’s Thyroiditis With Negative Antibodies In Association With Common Variable Immunodeficiency
Authors: Ebrahim Ismail C , Brown Kevin F , Vietor Nicole O , Duc Hoang Thanh , Shakir Mohamed K M
Published: October 2023

Disclosure: I.C. Ebrahim: None. K.F. Brown: None. N.O. Vietor: None. T.D. Hoang: None. M.K. Shakir: None.

Introduction: Common variable immunodeficiency (CVID) is associated with several autoimmune manifestations including Hashimoto’s thyroiditis (HT). We report a 47-year-old male with CVID and HT with negative thyroid antibodies (Abs). Case Report: A 47-year-old male, while undergoing coronary calcium scan in 2021, was found to have scattered lung nodules. Follow-up Ct scans showed interval increase in size of lung nodules and a PET scan confirmed bilateral lung nodules which demonstrated hypermetabolic activity and scattered hypermetabolic lymph nodes, suggesting infectious or inflammatory processes. PET scan also revealed thyromegaly with diffusely increased uptake, suggesting thyroiditis. Serum immunoglobulins were measured: IgA < 5 mg/dL (normal 70-400), IgG 334 mg/dL (normal 700-1600), and IgM < 25 mg/dL (normal 40-230). Serum immunoglobulins levels from depository serum samples collected in 2005 also showed similarly low values. CBC was normal, excluding any bone marrow disorders. There was no family history of immunodeficiency or thyroid disorders. On review of systems patients did not have any symptoms of hypothyroidism. Exam: thyroid 50-gms diffusely enlarged with no palpable nodules; heart and lung exam was normal. Laboratory tests including comprehensive metabolic panel, serum complement CH 50, leukemia/lymphoma panel, T/B - lymphocyte/Natkiller, CRP were all normal. Thyroid functions: TSH 5.6 mc1U/mL (0.27-4.2), Free T4 1.20 ng/dL (0.93-1.71), TPO Ab < 9 IU/mL (0-34), TG Ab < 1.0 1U/mL (0.0-0.9), thyrotropin receptor Ab < 0.3 IU/L (<1.0), thyroid stimulating immunoglobulin < 0.10 1U/L (0.06-0.55). Serum thyroid Ab levels from depository samples collected in 2005 also showed normal values. FNA of thyroid showed atypical lymphoid infiltrates and an excision biopsy of the thyroid isthmus confirmed lymphocytic thyroiditis. A PET avid right inguinal lymph node biopsy showed a reactive lymph node. Additional lab evaluation also showed low post vaccination pneumococcal titers. With pan-hypoglobulinemia and low vaccine response, a diagnosis of CVID was made. Patient preferred watchful waiting than iv immunoglobulin therapy. Additionally, the patient has HT with negative thyroid Abs and although patient had mild subclinical hypothyroidism patient elected no treatment. Common variable immunodeficiency (CVID) is the most frequent symptomatic primary immunodeficiency in adults. Autoimmune manifestations occur in 22% of CVID patients and these include autoimmune cytopenia, pernicious anemia, rheumatoid arthritis, vitiligo, and/or HT. Interestingly, our patient did not manifest any thyroid Abs thus it may be postulated that thyroid follicles destruction in HT is mediated predominantly by thyroid-specific B and T cells rather than by thyroid antibodies.

Presentation: Friday, June 16, 2023
SAT554 Follicular Variant of PTCA Initially Presenting with Widespread Metastases
Authors: Natividad Bisquera Nichole Andrea , Mirasol Roberto Cachola
Published: October 2023

Disclosure: N.N. Bisquera: None. R.C. Mirasol: None.

Background: Papillary thyroid carcinoma accounts for most cases of thyroid cancer. Most cases of PTC have a good prognosis and low incidence of metastases. The follicular variant is the most common variant. First described in the 1960’s, the understanding of FV-PTC began to evolve with molecular profiling demonstrating a similarity with FTC, and clinical behavior profiling showing that a subtype may behave like PTC with a propensity for lymph node metastases. We are presented with an unusual case of an infiltrative FV-PTC presenting with widespread multiple metastases on diagnosis. Clinical Case: A 64-year-old female, presented with 1-year history of a slowly enlarging mass on the left mandible, which was also associated with an enlarging anterior neck mass. She had no constitutional symptoms and had previously been in good health. On examination, there was a 7x8x3 cm hard, fixed left mandibular mass. There was also a palpable right thyroid nodule measuring 2.5x2 cm. There was no difficulty in swallowing or breathing, but she had some difficulty in eating due to trismus. There were no associated symptoms of hypo/hyperthyroidism. Investigations revealed a euthyroid status. CT scan showed a solid lobulated heterogeneously enhancing mass measuring 4.2x5.1x5.2cm on the body and angle of the left mandible. Ultrasound showed multiple thyroid nodules, the largest - a mixed cystic and solid mass measuring 2.9 x 2.7 x 2.17 cm on the right thyroid lobe, for which FNA was performed. Histopathology showed benign follicular nodules. Incision biopsy of the mandibular mass showed presence of thyroid tissue. Further imaging showed metastases to the left frontal, parietal bone, T7 vertebra, and bilateral lungs. The case was discussed in a multi-disciplinary tumor board meeting. With a pre-operative diagnosis of a primary thyroid malignancy, the patient then underwent a total thyroidectomy with segmental mandibulectomy. Post-operative histopathology showed a metastatic multifocal infiltrative follicular variant of PTC. RAI was administered post-surgery, and she was started on suppressive thyroxine therapy. Steroids were given during RAI, with no untoward events post treatment. Post-ablative whole body scanning revealed increased tracer uptake in multiple areas: left frontal and parietal bone, bilateral thyroidal beds, left supraclavicular lymph node, the sternomanubrial junction, bilateral lung lobes, right humeral head and T7 vertebra. Further doses of RAI was planned and she is currently maintained on suppressive thyroxine therapy. Conclusion: Diagnosis of FV-PTC may be a greater challenge than conventional forms because of possible false-negative results on cytology. The infiltrative subtype has greater metastatic potential and higher recurrence rates. Multidisciplinary team management and careful preparation prior to treatment with RAI is indicated in these cases.

Presentation Date: Saturday, June 17, 2023
SAT312 CT-guided Cryoablation Of Hereditary Pheochromocytoma
Authors: Griffing Emily , Reading Brenton , De Luca Francesco
Published: October 2023

Disclosure: E. Griffing: None. B. Reading: None. F. De Luca: None.

Background: Guidelines surrounding the management of hereditary pediatric pheochromocytomas (PHEO) are lacking. This is the first report of a pediatric patient with bilateral hereditary PHEO treated with right adrenalectomy and computed tomography (CT) percutaneous-guided cryoablation (CRA) of the left-sided lesion.Clinical case: A previously healthy 15 years-old male presented to a tertiary care hospital with a months-long history of episodic chest pain, flushing, shortness of breath, diaphoresis, and tremulousness. Paternal family history was significant for PHEO and brain stem hemangioblastoma in grandmother and PHEO in the great-grandfather. Targeted familial mutation analysis of the von Hippel-Lindau tumor suppressor gene was positive for pathogenic mutation c.500G>A (p.R167Q). Plasma free normetanephrine level was 4,625 pg/mL (nl: <145 pg/mL), while free metanephrines were normal. Magnetic-resonance imaging of the abdomen visualized a 4.4 x 3.4 x 5.3 cm right adrenal mass and a 1.4 x 1.4 x 1.4 cm left adrenal mass, consistent with bilateral PHEO. He underwent right adrenalectomy after initiation of alpha-receptor blockade and later addition of beta-receptor blockade due to heart rates in the 150’s. After discussion with parents, it was decided to observe the smaller left-sided adrenal lesion. Plasma free normetanephrines initially decreased to 338 pg/mL, but then increased to 507 pg/mL five months post-operatively. Six months after surgery, due to the persistence of hypertension with systolic blood pressure in the 140’s as well as tachycardia with heart rates in the 150’s, he underwent CT-guided CRA of the left-sided PHEO. A 12-minute freeze, 5-minute thaw, and 10-minute freeze, followed by an active thaw were performed. There was an increase in blood pressure during the initial thaw with systolic blood pressure in the 230s, accompanied by bradycardia to the 30s, treated with nitroprusside, phentolamine, and increased sedation. He required continuation of nitroprusside infusion for five hours post-procedure. He was discharged the following day with normal blood pressure and heart rate. He was able to completely wean off anti-hypertensive medications within one month and symptoms of chest pain and tachycardia resolved. In the four years since his procedure, he has not had a recurrence of PHEO nor development of adrenal insufficiency. Plasma free normetanephrines and metanephrines have remained within normal limits. Conclusion: Percutaneous ablation of hereditary PHEO has not been reported before in the pediatric population and may represent a novel treatment strategy that reduces the risk of adrenal insufficiency.

Presentation: Saturday, June 17, 2023
THU420 Analysis Of Factors Affecting Bone Mineral Density In Children And Adolescents With Systemic Lupus Erythematosus
Authors: Ahn Moon Bae , Park Su Jin , Suh Byung-Kyu
Published: October 2023

Disclosure: M. Ahn: None. S. Park: None. B. Suh: None.

Background: Children and adolescents with chronic disease are at risk of developing bone fragility. In particular, low bone mineral density(BMD) is increasingly recognized in pediatric patients with glucocorticoid treated rheumatic disease. The purpose of this study was to evaluate the clinical characteristics of children and adolescents with systemic lupus erythematosus(SLE), and to analyze the factors associated with a lower BMD in these patients.

Methods: Children and adolescents diagnosed with SLE who had received GC treatment were included. Clinical and laboratory data including anthropometry, GC exposure, other anti-rheumatic drug treatment, biochemical markers related to bone metabolism, serologic markers of disease activity in SLE, lateral thoracolumbar(D-L) spine radiography, and BMD were collected. Lumbar spine bone mineral density (LSBMD) was measured by Dual-energy x-ray absorptiometry(DXA). The correlation between BMD and anthropometry, steroid and anti-rheumatic treatment, biochemical variables was investigated. Results: A total of 30 patients with median age of 17.5 years (range 12 -25years) were included. Of the 29 patients who had DXA done, 7 patients had LSBMD z score lower than −2.0, and diagnosed as osteoporosis. SLE patients with osteoporosis were compared with those with a z score higher than −2.0. These patients had longer GC exposure, higher cumulative GC dose, longer hydroxychloroquine exposure. The main factor correlated with a low BMD was duration of GC exposure. BMD was positively correlated with height at diagnosis. Bone metabolic markers and serologic markers of disease activity in SLE had no significant correlation with BMD. Conclusion: Children and adolescent SLE patients with OP had longer GC exposure, higher cumulative GC dose compared with those with LSBMD z score higher than −2.0. The main factor correlated with a low BMD was duration of GC exposure. Therefore, efforts should be made to reduce the duration of GC exposure and reduce medication to the lower possible maintenance dose. Since longer treatment duration affects BMD, close monitoring during the treatment period is recommended to prevent further loss of bone mass in pediatric SLE patients.

Presentation: Thursday, June 15, 2023
FRI650 Effectiveness Of Non-pharmacological Strategies In The Management Of Type 2 Diabetes In Primary Care: A Systematic Review And Network Meta-analysis
Authors: Giacomini Occhiuto Renata , Banzato Luisa , Lucia Mendes Adriana , Bolfi Fernanda , Santos Nunes-Nogueira Vania dos
Published: October 2023

Disclosure: R.G. Occhiuto: None. L. Banzato: None. A.L. Mendes: None. F. Bolfi: None. V.D. Nunes-Nogueira: None.

Introduction: Despite the increasing number of drugs and various guidelines on the management of type 2 diabetes mellitus (T2DM), several patients continue with the disease uncontrolled. There are several non-pharmacological treatments available for managing T2DM, but various of them have never been compared directly to determine the best strategies. Objective: This study has evaluated the comparative effects of non-pharmacological strategies in the management of T2DM in primary care or community settings. Methods and Analysis: We have performed a systematic review and network meta-analysis (NMA) and have include randomized controlled trials if non-pharmacological strategies in the management of type 2 diabetes were applied in adult patients with T2DM in primary care. The primary outcome was glycemic control (glycated hemoglobin [HbA1c] [%]). We have developed search strategies for Embase, Medline, Latin American and Caribbean Health Sciences Literature, Cochrane Central Register of Controlled Trials, Trip database, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Australasian Medical Index, and Chinese Biomedical Literature Database. Four reviewers have assessed the studies for their eligibility and their risk of bias in pairs and independently. A NMA have been performed using Stata Statistical Software 17 (Stata Statistical Software: Release 17. College Station, TX, StataCorp LLC, USA). Results: After removing duplicates, the search strategies yielded 4314 studies. After a thorough evaluation of the references, 129 studies encompassing a total of 35975 individuals have been included in this review. Twenty and three strategies were founded. The most frequent strategy was diabetes self-management and support (DSMES) (60%), followed by diabetes self-management education (22%), self-monitoring of blood glucose (7%) and health coach (5). The most frequent comparator has been usual care (92%). Regarding relative rankings of treatments, the NMA has showed that nutritional therapy plate method has a 37.6% probability of being the best treatment in terms of HbA1c reduction, followed by DSMES associated with social support (24%) and low-fat diet (19.6%). Conclusion: This review has founded 23 non-pharmacological strategies in the management of type 2 diabetes in primary care, being the most frequent DSMES. Grant FAPESP:2021/07229-0

Presentation: Friday, June 16, 2023
FRI665 Hirata's Syndrome: Autoimmune Hypoglycemia Diagnostic Pathway, A Mexican Case Report
Authors: De La Cruz German Gonzalez , Porras Farret Diego
Published: October 2023

Disclosure: G. Gonzalez De La Cruz: None. D. Porras Farret: None.

Introduction: Autoimmune hypoglycemia or Hirata syndrome is a very rare cause of hypoglycemia in western populations, as an example, in Mexico until 2015, there was only a single case reported with these characteristics. Diagnosis is based on episodes of spontaneous, fasting or postprandial hypoglycemia, with endogenous hyperinsulinism, without pancreatic lesions on imaging and positive tests. Objective: To describe the approach to a patient with hypoglycemia, specifically to those with characteristics of autoimmune hypoglycemia syndrome, as well as the general approach to hypoglycemia of endogenous origin and the differential approach in those with a history of type 2 diabetes or drug use with secondary effects. Case description: An 86-year-old woman with a history of high blood pressure, prediabetes, and osteoporosis, presented episodes of dizziness, palpitations, diaphoresis, and syncope, documenting plasma glucose of 40 mg/dl. She was attended by paramedics responding adequately to oral glucose. She was evaluated by Cardiology, Holter was performed with predominant sinus rhythm, frequent atrial extrasystoles (2%) and infrequent ventricular extrasystoles. Next, she was referred to Endocrinology for evaluation and treatment, she was taken empagliflozin as prediabetes medication, and it was suspender. Laboratory studies are requested to address hypoglycemia, with serum insulin levels greater than 600 mU/l, c-peptide 3.9 ng/ml, TSH 6.1, T4T 7.5, T3T 67.8, T4L 1.1, ALT 26 U/L, AST 18 U/L, DHL 247 U/L, GGT 26 U/L, Cortisol 13.8 mcg/dl. An MRI of the upper abdomen was performed where there is no evidence of pancreatic injury. A profile of serum hypoglycemic agents (sulfonylureas in blood) was requested, which were not detected. Subsequently, anti-insulin studies were requested, which were reported in amounts greater than 100 U/ml. The diagnosis of autoimmune hypoglycemia syndrome was made, starting management with prednisone 70 mg every 24 hours, in addition to dietary changes. Conclusion: The approach to hypoglycemia in patients without clear evidence of exogenous administration of hypoglycemic agents must be ordered, taking into account differential diagnoses such as autoimmune causes. In the case of autoimmune hypoglycemia, remission is expected at 6 months, with constant monitoring and adjustment of drugs for underlying pathologies.

Presentation: Friday, June 16, 2023
OR18-04 Leptin Decreases Gluconeogenesis And Gluconeogenic Substrate Availability In Patients With Lipodystrophy
Authors: Quaye Emmanuel , Chacko Shaji , Startzell Megan , Brown Rebecca J
Published: October 2023

Disclosure: E. Quaye: None. S. Chacko: None. M. Startzell: None. R.J. Brown: Other; Self; Metreleptin for the study was donated by Amryt Pharma.

Leptin is an adipocyte-derived hormone that signals overall energy sufficiency. In patients with lipodystrophy, treatment with recombinant leptin (metreleptin) improved measures of glycemia and decreased energy expenditure. We hypothesized that metreleptin in patients with lipodystrophy would decrease gluconeogenesis (GNG) and gluconeogenic substrates through improvements in peripheral and hepatic insulin sensitivity.

We conducted a single-arm prospective study of metreleptin administration in 9 patients with lipodystrophy from 2013-2018. The main outcomes of this study were basal and insulin-mediated suppression of GNG, carbon sources for GNG (glycerol rate of appearance (Ra) measured with isotope tracers, and plasma alanine and lactate), palmitate Ra (a driver of GNG, measured with isotope tracers), and peripheral and hepatic insulin sensitivity (measured as glucose disposal during a hyperinsulinemic clamp, and % suppression of glucose Ra during the clamp, respectively).

Peripheral insulin sensitivity increased 2-fold (by 115±134%; P=0.001) after 6 months of metreleptin. Hepatic insulin sensitivity increased from 61% to 81% after 6 months of metreleptin with a trend toward statistical significance (P=0.08; 6 months vs. baseline). Basal GNG decreased by 16±12%, from 12.4±3.9 to 10.9±2.6 µmol/kgLBM/min, after 2 weeks of metreleptin (P=0.02) but did not change after 6 months (P=0.2). Metreleptin increased insulin-mediated suppression of GNG during the hyperinsulinemic clamp from 73% at baseline to 91% after 2 weeks (P<0.002; 2 weeks vs. baseline), and 94% after 6 months (P<0.001; 6 months vs. baseline). Alanine was unchanged after 2 weeks of metreleptin (P=0.1) but decreased by 21±22% after 6 months (P=0.005). There was a positive correlation between alanine and GNG at baseline (r=0.8, P=0.01), 2 weeks (r=0.8, P=0.03) and 6 months (r=0.9, P=0.002). Lactate decreased by 20±18% after 2 weeks (P=0.014) and 21±24% (P=0.001) after 6 months of metreleptin. There was no significant decrease in glycerol or palmitate Ra after 2 weeks of metreleptin, but palmitate Ra decreased after 6 months (P=0.04). Metreleptin treatment in patients with lipodystrophy reduced basal GNG and increased insulin mediated suppression of GNG. Reduced GNG may be mediated by improved insulin sensitivity leading to reductions in alanine and lactate, which are carbon sources for GNG. Associations between alanine and GNG persisted after metreleptin, suggesting that potential therapeutic interventions to reduce protein turnover in insulin-resistant states may improve glucose homeostasis.

Presentation: Saturday, June 17, 2023
SAT031 The Effect Of Metformin On Increasing Glucose Metabolism And Secretion In The Distal Intestine
Authors: Ho Nam Jung , Woo Kang Chan , Hun OH Ju , Kyung Wang Eun , Hyun Lee Soo , Won Hong Jae , Jig Lee Eun , Ryong Ku Cheol
Published: October 2023

Disclosure: J. Nam: None. C. Kang: None. J. Oh: None. E. Wang: None. S. Lee: None. J. Hong: None. E. Lee: None. C. Ku: None.

Object: Although the effect of metformin is widely known, little research has been performed on clinical significance and potential mechanism of increased intestinal glucose uptake which is commonly found in [18F]-fluoro-D-glucose (FDG) positron emission tomography. The aim of this study is to assess the altered glucose metabolism in the combined colon and terminal small intestine after metformin treatment. Material and Method: Radioactivity of FDG was measured in metformin treated mouse to evaluate the glucose uptake in the various tissue. qPCR and immunoblot were performed to examine the glucose metabolism in small intestine and colon. Autoradiography and gamma counts were used for measuring FDG uptake in small intestine and colon. IEC6 and Caco-2 cell lines were used for small intestine and colon respectively for in vitro experiment. Result: 150mg/kg metformin treatment for 7 days improved glucose homeostasis in c57BL6 mice (AUC 0.8- fold, p<0.05). Gradual increase in FDG absorption was observed along the intestine in an autoradiography and gamma counter. Especially distal ileum (9-fold, p <0.0001) and colon (15-fold, <0.0001) showed increased glucose uptake than proximal intestine (Duodenum no significance, Jejunum 3-fold, P<0.01). Interestingly, glucose content in the fecal flush was elevated in metformin treated mice (13.5-fold, p<0.01). In line with the in vivo result, metformin enhanced glucose uptake in IEC6 (3-fold, p<0.01) cell compared to the non-treat control cells (NT). qPCR and Immunoblot results showed that metformin treatment enhanced GLUT1 expression (1.6-fold, p<0.01) compared to the NT. Hexokinase2 (HK2), known as glycolysis marker, shown to be increased (1.4-fold, p<0.01) by the metformin treatment in IEC6 and Caco-2 cells compared to the NT. GLUT1 expression was also increased in the metformin treated mice small intestine and colon than in vehicle treated mice. Conclusion: Taken together, our data suggest that metformin increases the glucose metabolism of distal small intestine and colon by the upregulation of GLUT1 expression. Enhanced glucose metabolism induced by metformin was correlated with the improved glucose homeostasis. Our data suggests the novel mechanism of metformin in the G.I tract that involved to some extent in the disposal of excess glucose in in vitro and in vivo system.

Presentation: Saturday, June 17, 2023
SAT036 Chlorthalidone Implicated In The Development Of DKA HHS Overlap In A Patient With Type II Diabetes Mellitus
Authors: Hilder Robin T
Published: October 2023

Disclosure: R.T. Hilder: None.

Introduction: Thiazide diuretics are routinely used in the management of hypertension and impaired glucose tolerance is a well-known side effect of these medications. This case reports on a patient with type II Diabetes Mellitus newly initiated on Chlorthalidone, presenting with complications of profound hyperglycemia consistent with an overlap of HHS (Hyperglycemic hyperosmolar state) and DKA (Diabetic ketoacidosis). Case: A 61-year-old Hispanic male with history of Hypertension, Hyperlipidemia, Left Cerebellar Hemorrhage and Type II Diabetes Mellitus on Metformin 500mg twice daily, presented with a 2-month history of fatigue, polyuria and polydipsia. Lab work was significant for blood glucose 908 mg/dl, pH 7.28, HCO3 15, Anion Gap 25 and elevated beta-hydroxybutyrate of 10.82 mmol/l. HbA1c was 12.7%, up from 8.8% three weeks prior. C-peptide 0.7 ng/ml and GAD-65 Ab <5 IU/ml. For hypertension, the patient was adherent with titrated doses of Amlodipine, Benazepril and Hydralazine and newly initiated on Chlorthalidone 25mg daily, 2 weeks prior. There were no infectious signs or symptoms nor alternative precipitant for the hyperglycemia identified. The patient was admitted to the ICU for an overlap of DKA and HHS. The anion gap closed, and acidosis resolved within 24 hours with IV fluid resuscitation and Insulin drip on DKA protocol. He was discharged on Glargine 30 units daily, Lispro 8 units three times daily with meals and Metformin 500mg BID. Discussion: This patient’s presentation of hyperglycemia and ketosis in the absence of profound acidosis is suggestive of HHS, consistent with his protracted course preceding admission. His elevated beta-hydroxybutyrate however is more typically associated with DKA. With no other precipitant for the severe hyperglycemia and rapid rise in HbA1c identified, Chlorthalidone is the likely trigger. Thiazide diuretics are recognized to cause impaired glucose tolerance but there are few case reports on the development of HHS/DKA. The severity of this presentation in a patient otherwise routinely prescribed Chlorthalidone as an outpatient, without indication for blood glucose monitoring, highlights the need for greater research and awareness for this potentially fatal complication.

Presentation: Saturday, June 17, 2023
Popular Votes on Tobacco Tax Increases, 2012–2022
Authors: Ferraiolo Kathleen
Published: October 2023

Context: Researchers have examined the campaign strategies, messaging, and outcomes of popular votes on tobacco tax increases from 1998 to 2008, but no study has investigated measures that have appeared since 2008.

Methods: The author uses state newspaper archives, voter pamphlets, academic reports, advocacy websites, and personal interviews to obtain information about the 11 tobacco tax increase ballot measures that appeared from 2012 to 2022.

Findings: The three measures that succeeded during 2012–2022 featured sufficient financial resources, collaboration with influential stakeholders, and early public support. Two of the three successful measures offered significant concessions to the tobacco industry, and both were designed as legislatively referred statutes. Elsewhere, proponents sought unsuccessfully to enact citizen-led initiatives that would allocate revenue to progressive policy priorities. In contrast to previous eras, tobacco industry arguments often centered around antitax and antigovernment rhetoric, which was viewed as especially compelling in conservative states. The industry's success rate was higher than in the past, and it continued to outspend its opponents, sometimes by staggering margins.

Conclusions: Campaign spending and early support remain critical to the success of tobacco tax ballot measures. Big Tobacco can extract significant concessions even in defeat, and direct democracy is an effective but imperfect ally to tobacco control advocates.
Effectiveness of Integrated Emotional-Self Enhancement (IESE) program among staff nurses: protocol for a quasi-experimental study
Authors: Saikia Monalisa , George Linu Sara , Unnikrishnan Bhaskaran , George Anice , Ravishankar N
Published: October 2023

Background: Staff nurses face frequent emotional situations in their work environment. The constant contact with suffering patients, and the busy work environment, pose tremendous stress on nurses' physical and emotional health. The Emotional Intelligence skills of empathy, self-awareness, motivation, self-control, and keeping relationships, can help handle difficult emotions and allow nurses to work in an organized, calm, and professional way.

This study aims to implement and assess the effectiveness of a training program developed by the investigator, tailored to the mental and emotional needs of staff nurses who are working in an organisation. The study also aims to observe any significant change, correlation, and association in the staff nurses’ level of emotional intelligence, intrinsic motivation, self-compassion, emotional labour, and nurse-in-charges’ and patients’ perception of nursing care after the program.

Methods: A quasi-experimental (one-group) study design will be used in this study. The study will involve 80 staff nurses working in a selected hospital in India. The staff nurses will be selected from the hospital's general wards using convenience sampling. The investigator will deliver a training program, divided into four sessions of two hours each. Data will be collected from the participants at baseline and 3-months pre-intervention; and post-test data will be collected immediately after the intervention, at 3-month, and 6-month follow-up, to observe any significant change in the study variables before and after the intervention.

Results: The current study primarily focuses on the vital aspect of developing emotional needs, for promoting a better work-life balance. Research findings from the study will significantly contribute to the evidence-based Emotional Intelligence programs for staff nurses, and if proven effective, could be delivered extensively in hospitals.

Trial registration: The study is registered in June 2019 under the Central Trial Registry of India (CTRI/2019/08/020592).
The prevalence of cyclothymic disorder among first-year students at a health sciences university in Central India
Authors: Quazi Anam , Berry Svanjita , Logue Rachel , Gaidhane Shilpa , Parve Swapnil
Published: October 2023

Background: Cyclothymic disorder includes hypomanic and depressive symptoms that do not meet standards for hypomanic episodes and major depressive symptoms.

Objectives: To assess the prevalence of cyclothymic disorders in medical, physiotherapy, and dental 1st-year students aged 18–22 years old in Datta Meghe Institute of Higher Education and Research (DMIHER), Wardha.

Methods: The study is designed as a cross-sectional study where a web-based survey will be used to evaluate the prevalence of the cyclothymic disorder in 154 first-year Health Professional Education (HPE) students at a university in Central India.

Conclusions: This study will assess the prevalence of cyclothymic disorders in HPE students and investigate relationships between different fields of study, age, gender, socio-economic status, place of temporary residence (home/hostel/paying guest), history of addiction (smoking/alcohol/substance abuse/other), past medical history (physical and/or mental), and family history (divorced parents/history of childhood abuse).
Logros y lecciones de las experiencias en la gestión moderna durante la última década: una revisión sistemática
Authors: Rossi Valverde Ricardo Manuel , Rossi Ortiz Ricardo Gabriel
Published: October 2023

Esta investigación cualitativa y descriptiva se enfocó en dos objetivos: conocer los logros y lecciones aprendidas en la gestión moderna de la última década y analizar su relación en un contexto sistémico. La metodología se ciñó a la guía PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), utilizando cadenas de búsqueda y aplicando criterios de inclusión y exclusión, lo que permitió la identificación, tamizado y selección de un total de 50 artículos para su posterior revisión y síntesis. Los resultados destacan la importancia de la gestión sostenible como un elemento esencial para lograr ventajas competitivas, especialmente cuando se integra con enfoques de gestión adaptativa y principios de economía circular. Se subraya también el desafío que representa la gestión ágil en relación con las prácticas centradas en las personas y la gestión estratégica. En este contexto, se enfatiza la necesidad de integrar sistemas de información gerencial y de gestión de calidad en un sistema de gestión unificado. Se identificó una limitación significativa en la escasez de publicaciones que aborden la aplicación práctica de estos enfoques. Se recomienda llevar a cabo más estudios de casos para profundizar en la implementación y los resultados concretos en entornos empresariales y organizacionales.