bluuebunny/crossref_metadata_2025 huggingface dataset:
6857 Adrenal Incidentaloma In A Patient With Surgically Treated Lung Adenocarcinoma A Decade After Complete Remission
Authors: Kaur L , Kaur R , Haider F , Iqbal A , Patel N
Published: October 2024

Disclosure: L. Kaur: None. R. Kaur: None. F. Haider: None. A. Iqbal: None. N. Patel: None.

Adrenal incidentaloma is an adrenal mass >1 cm in size commonly discovered incidentally in up to 5-7% of patients on imaging performed for reasons other than adrenal causes. Metastasis to the adrenal glands is common due to their rich blood supply, with lung cancer being the most common primary site, followed by the stomach, esophagus and the liver. Bilateral adrenal metastasis is common, however isolated metachronous or synchronous adrenal metastasis is rare, with an incidence of 1-6%. We present a case of incidentally discovered isolated right adrenal mass ten years after curative surgical resection of right lung adenocarcinoma. A 74 year old male with history significant for adenocarcinoma of the right upper lung lobe stage 1A , negative for metastasis status post lobectomy and no adjuvant chemotherapy or radiation 10 years ago presented to the hospital for his routine follow up evaluation. His vitals were within normal limits and physical examination was unremarkable. The follow up diagnostic CT imaging was done which showed an incidental 2.1 x 1.6 x 1.2 cm right adrenal mass without any pathological lesion or lymphadenopathy. A review of CT scan done one year ago revealed no prior adrenal mass or other suspicious findings. The patient was referred to endocrinology for evaluation of the adrenal mass. He denied abdominal or right flank pain, headaches, palpitations, elevated blood pressure, sweating, muscle weakness, weight gain/loss and was healthy appearing. Lab work up including biochemical studies for hormonal over production, including aldosterone-renin ratio, adrenocorticotropic hormone, plasma catecholamines with urine metanephrines and urine cortisol were within physiological ranges. CT scan was repeated after 2 months which revealed right adrenal mass of 3.2 x 1.8 x 1.7 cm in size with heterogeneity and high pre contrast density. Given the patient's history of lung cancer, imaging characteristics and rapid interval increase in size, there was high suspicion for metastatic disease. Other differentials considered due to fast growth rate included adrenocortical carcinoma and less likely adrenal adenoma. A decision was made to proceed with right adrenalectomy for definitive resection and histological diagnosis secondary to quickly growing adrenal mass with no lymphadenopathy. The patient underwent laparoscopic adrenalectomy and the final pathological report was consistent with metastatic lung adenocarcinoma. Postoperatively the patient recovered well. At 2 week and 3 month follow up he reported no concerns. Isolated adrenal metastasis is unusual and rare but may occur in lung cancer patients years after curative resection of the primary tumor and hence long term annual follow up imaging and monitoring is recommended for prompt diagnosis and timely treatment.

Presentation: 6/2/2024
12325 Adrenocortical Carcinoma Masquerading As Pheochromocytoma In A Patient With Congenital Adrenal Hyperplasia
Authors: Marta Niedzialkowska Ewelina , Ahamad Banka Ajaz
Published: October 2024

Disclosure: E.M. Niedzialkowska: None. A.A. Banka: None.

Introduction: The development of adrenocortical carcinoma (ACC) in patients with congenital adrenal hyperplasia (CAH) is rare. The patients with CAH are at increased risk of adrenal tumors which is attributed to ACTH stimulation of adrenal gland if the disease is not appropriately treated. ACC cases mistaken for pheochromocytomas have been reported in the literature and are attributed to the variety of immunohistochemical markers expressed by the tumors. Case description:59 y.o female with salt-wasting CAH diagnosed at the age of 2 (21-hydroxylase deficiency) on hydrocortisone supplementation reported to the hospital due to episodes of sweating, tachycardia and hypertension. Work up revealed mildly elevated plasma normetanephrine 1 nmol/l (N <0.9), urine normetanephrine 1762 mcg (N<899), VMA 11.2 mcg/24hr (N 3.3-7.2). MRI of the abdomen revealed 2 left adrenal masses of 3.7 and 2.4 cm, right adrenal gland hyperplasia and low T1 and T2 enhancement. I-123 MIBG revealed increased activity and thickness of the right adrenal gland and no significant uptake on the left with nodular masses. The patient underwent left adrenalectomy with pathological report consistent with pheochromocytoma due to positive chromogranin and synaptophysin staining and moderate Ki activity. A year later follow up imaging showed an enhancing mass up to 7 cm at the suprarenal fossa invading the left kidney that was positive for nodular adrenocortical hyperplasia per pathology report. The patient continued to have elevated 17-OH- progesterone (2740 ng/l, N <51) despite compliance with her steroid therapy and suppressed ACTH. She underwent mass resection along with nephrectomy, splenectomy, partial colectomy and partial pancreatectomy. Pathology report was positive for adrenocortical carcinoma (positive chromogranin, synaptophysin, CAM 5.2, polycystic cytokeratin, Ki positive in greater than 10% of the tumor cells) with renal and regional lymph node invasion and colonic metastases. The patient was started on mitotane therapy but a year later PET scan was positive for liver and omental metastases and was subsequently started on carboplatin/etoposide followed by streptozocin/adriamycin with initial good response, however repeat PET a year afterwards showed progression of the liver lesions, metastases to omentum and metastatic lesion to calvarium and the patient expired soon afterwards. Discussion: CAH predisposes patients to adrenal tumors which is attributed to increased ACTH stimulation of the adrenal gland but ACC in this population is extremely rare. In very rare cases ACC can present clinically as pheochromocytoma with elevated catecholamine levels and positive synaptophysin and chromogranin staining which poses a clinical challenge. Both CAH and ACC can lead to increased androgen levels and ACTH levels can help to differentiate the origin of the hyperandrogenemia.

Presentation: 6/2/2024
7320 A Case Of Concurrent Lithium-Associated Hyperthyroidism, Nephrogenic Diabetes Insipidus, Primary Hyperparathyroidism, And Acute Pancreatitis
Authors: Buchanan C , Ellenburg C , Beasey M
Published: October 2024

Disclosure: C. Buchanan: None. C. Ellenburg: None. M. Beasey: None.

Background: Hyperthyroidism, nephrogenic diabetes insipidus, and hyperparathyroidism are all well-documented adverse effects of long-term lithium therapy. This report highlights a rare case of these three endocrinologic adverse effects occurring concurrently. Clinical Case: A 47-year-old man on long-term lithium therapy for bipolar disorder presented with slurred speech, fatigue, new tremor, and generalized muscle weakness. Laboratory testing was consistent with lithium toxicity with serum lithium level of 2.22 mmol/L (0.60-1.50). Thyrotoxicosis was present with a free T4 of 3.2 ng/dL (0.6-1.1) and TSH of 0.04 µlU/mL (0.24-5.60). CT of the neck revealed mild enlargement and heterogeneity of the left lobe of the thyroid gland. Methimazole was started. Calcium corrected for albumin was elevated at 12.4 mg/dL (8.6-10.0) and PTH was also elevated at 146.0 pg/mL (12.0-88.0). Serum sodium was elevated at 160 mmol/L (136-145) with urine osmolality of 327 mOsm/kg. DDAVP was trialed in addition to IV hypotonic fluids, although it had little effect. Acetazolamide was started a few days later with subsequent normalization of the serum sodium level. Acetazolamide was later discontinued in favor of hydrochlorothiazide because of the development of non-anion-gap metabolic acidosis. A dose of zoledronic acid was given and cinacalcet was started. Serum calcium normalized over the following week. The patient acutely developed right upper quadrant abdominal pain, nausea, and emesis on hospital day 13. Lipase was elevated at 575 u/L (11-82). CT of the abdomen demonstrated moderate inflammatory changes along the pancreas and duodenum. Acute pancreatitis was diagnosed. There were no gallstones or acute biliary tract abnormalities seen on ultrasound. The patient’s symptoms gradually improved and he was discharged from the hospital after a total of 18 days. Lithium was discontinued indefinitely. TSH and free T4 normalized within 3 months. He had continued to require hydrochlorothiazide, methimazole, and cinacalcet at the time of his 3-month primary care follow-up appointment. Conclusion: Despite its efficacy and widespread use in mood stabilization, lithium has a narrow therapeutic window and is strongly associated with several serious, sometimes irreversible, adverse effects. Routine monitoring of lithium levels, serum calcium, and thyroid hormone levels is required. Lapses in routine monitoring may, as in this case, result in significant morbidity and prolonged hospitalization.

Presentation: 6/1/2024
5133 A Rare Case Report Of Hypoketotic Hypoglycemia Induced Seizures In A 44-Year-Oldfemale
Authors: Alrestom Roua , Bangolo Ayrton , Elias Sameh , Sekhon Imranjot
Published: October 2024

Disclosure: R. Alrestom: None. A. Bangolo: None. S. Elias: None. I. Sekhon: None.

Carnitine deficiency is a rare metabolic condition that can result in fasting hypoglycemia. Carnitine deficiency could be primary or secondary to other conditions. Among secondary causes, antiepileptics such as valproic acid have been incriminated. Herein we report the case of a 44-year-old female with epilepsy that presented with breakthrough seizures associated with hypoglycemia despite being on appropriate antiepileptic therapy. The patient was later found to have carnitine deficiency. Discontinuation of valproic acid and supplementation with L-carnitine resolved the patient’s hypoglycemia and breakthrough seizures. With this case report, we hope to encourage clinicians to include carnitine deficiency in the differential diagnosis of unexplained hypoglycemia.

Presentation: 6/1/2024
7137 The Sugar Saga: A Profound Case Of Diabetic Ketoacidosis Due To Enfortumab Vedotin
Authors: Aron Polina , Connell Brendan , Longo Rebecca , St. Jean Karen , Upadhyay Jagriti
Published: October 2024

Disclosure: P. Aron: None. B. Connell: None. R. Longo: None. J. Upadhyay: None.

This is a case of severe hyperglycemia with the use of Enfortumab Vedotin (EV) in the setting of advanced urothelial cancer. EV is a nectin-4-directed antibody-drug conjugate with a microtubule inhibitor approved for treating advanced/recurrent disease. It is the first of its class that is an antibody-drug conjugate (ADC), targeting nectin, but not the first ADC to cause hyperglycemia. Here we present a case of severe insulin resistance requiring insulin infusion at 50 units/hour in addition to subcutaneous insulin all in the setting of EV use.74 year old male with BMI of 28 and HbA1c of 7.5%, managed only with diet was started on EV for metastatic urothelial cancer. Patient received one cycle (3 doses) of EV (on days 1, 8, 15) and thereafter noticed worsening of hyperglycemia with blood glucose of 533 mg/dL, requiring subcutaneous insulin. Patient’s blood glucose readings remained elevated and he was admitted to the hospital as he was found to be in DKA with a pH of 7.2, bicarbonate 14 mmol/L, anion gap of 16 mmol/L and a glucose of 558 mg/dL. The patient was started on intravenous insulin (IV) infusion using insulin infusion protocol titrated up to 14 units an hour with an additional 30 units of glargine. Patients’ clinical condition continued to worsen and he was in septic shock with pressors and on insulin infusion exceeding 55 units/hour, NPH at 50 units, and regular insulin 30 units with glucose persistently above 400 mg/dL. Patient was started on hydrocortisone 50mg every 6h and his blood glucose readings eventually normalized over a span of 1 week. Patient eventually was able to be discharged to rehabilitation with just a correctional humalog insulin. Our case demonstrates DKA as a consequence of severe insulin resistance seen as a side effect of EV. Hyperglycemia is seen in 8% of patients using this medication, but severe cases are mostly seen with high BMI and uncontrolled diabetes. This case illustrates the fact that one needs to be cautious in ALL patients with diabetes when using this drug and warrants screening for DKA/severe insulin resistance if blood glucose is running >250mg/dL. The exact mechanism for hyperglycemia is unknown but it is likely immunomodulatory and therefore treatment with pulse dose steroids may help with overcoming insulin resistance in this setting like in our patient. More research needs to be done to understand mechanisms and establish treatment guidelines for severe insulin resistance and hyperglycemia caused by this medication.

Presentation: 6/1/2024
6631 A Week With Diabetes: Using Real-Time Continuous Glucose Monitoring In A Simulation Activity With Residents And Fellows
Authors: Gallagher Thomas , Donelly Colin , Amori Renee E
Published: October 2024

Disclosure: T. Gallagher: None. C. Donelly: None. R.E. Amori: None.

Background: Continuous glucose monitor (CGM) use in managing diabetes mellitus is increasing rapidly. Fellows and residents often prescribe these devices, but most do not themselves have diabetes mellitus and do not use these devices personally. A real-time simulation activity can help physicians in training learn about using the technology in diabetes management and the patient experience living with diabetes mellitus. Objective: Assessing learner’s experiences using a one week real-time CGM simulation. Methods: A real-time simulation using CGM and elements of role playing can enhance knowledge of CGM use and overall diabetes care. Voluntary participants included endocrinology fellows, internal and family medicine residents, and one health professions student. One common structured learning task per day was assigned to all participants over a single seven day period of use in academic year 2022-23. Assessment of each task occurred via personal observations and reflections. Data was collected in an anonymous form and in a group debrief. Results: Eight of 10 participants completed the deidentified post simulation survey and 8/10 participated in the live debrief. Participants reported ease of CGM placement and use. They reported improved insight into the impacts of diabetes on daily activities and increased awareness of diet and exercise impact on glucose levels. Insulin dose calculations were largely correct but errors were seen. All felt the activity was beneficial to their learning. Conclusions: Real-time CGM simulation improves student, resident, and fellow knowledge of the technology and allows the learner to gain insight into a patient’s diabetes self-management.

Presentation: 6/3/2024
7877 Adipose Depot Differences In Regenerative Properties Of Exosomes Derived From Human Adipose Stem Cells
Authors: Krause-Hauch Meredith A , Patel Rekha , Osborne Brenna , Albear Paul , Patel Niketa A
Published: October 2024

Disclosure: M.A. Krause-Hauch: None. R. Patel: None. B. Osborne: None. P. Albear: None. N.A. Patel: None.

Many patients struggle with chronic recalcitrant wounds that are the result of delayed healing. Underlying inflammation is one major risk factor for impaired dermal wound healing that may lead to pathologies such as infection and scarring. Adult human adipose stem cells (hASCs) have shown tremendous potential in regenerative medicine. The regenerative potential of hASCs is dependent on secreted bioactive material which is packaged and released in extracellular exosomes. We previously showed that hASC exosomes from the subcutaneous depot (sc) promoted repair in human dermal fibroblasts using in vitro assays. In this study, we evaluated exosomes derived from the omental depot (om) of hASC and compared its efficacy with sc-hASC. Our results show differences in levels of the long noncoding RNA (lncRNA) cargo between om-hASCexo and sc-hASCexo. Next, we evaluated their repair potential in a wound model in vivo. Male and female F344 rats were dorsally wounded via punch biopsy and silicone scaffolding was attached to prevent contraction. The wounds were then either not treated (control) or treated with 50μg om-hASCexo or sc-hASCexo every alternate day when each wound size was measured for 1 week to monitor healing progress. After 7 days, wounds treated with either om-hASCexo and sc-hASCexo closed significantly faster than untreated control wounds. While no difference was observed in closure percentage after 7 days for wounds treated with either om-hASCexo and sc-hASCexo, sc-hASCexo appeared to act faster earlier (1-2 days post wound) in the wound healing process while om-hASCexo acts faster during later stages (2-4 days post wound) of wound healing. The wound tissue was collected for biochemical and histological analysis. qPCR analysis on day 7 revealed that both om-hASCexo and sc-hASCexo treatment resulted in increased levels of Collagen 1 & 3 and MMP9, while levels of TGF-β decreased with treatment. These results indicate that om-hASCexo and sc-hASCexo enhanced the wound healing process while decreasing inflammation of the wound. To determine the differences between om-hASCexo and sc-hASCexo treatments on wound healing pathways, RNAseq was performed. Results show specificity in pathway activation and gene expression between the om-hASCexo and sc-hASCexo treatments. In conclusion, we have demonstrated that the regenerative mechanisms differ between the hASC depots from which exosomes are secreted. At a broader level, this finding may shed light on the body’s organ health and repair processes in normal or disease states.

Presentation: 6/3/2024
8707 Are We Adequately Prescribing Sodium-Glucose Cotransporter 2 Inhibitors (SGLT2i) Or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) In Patients With Type 2 Diabetes Mellitus (T2DM) And Established Atherosclerotic Cardiovascular Disease (ASCVD) Or Chronic Kidney Disease (CKD) In An Outpatient Setting: A Community Center Experience
Authors: Maan R K , Sawhney A , Hayat A , KC S , Madan A , K C S , Williams L , Zweben A , Rana A
Published: October 2024

Disclosure: R.K. Maan: None. A. Sawhney: None. A. Hayat: None. S. Kc: None. A. Madan: None. S. K c: None. L. Williams: None. A. Zweben: None. A. Rana: None.

Introduction: The American Diabetes Association (ADA) recommends prescribing Sodium-Glucose Cotransporter 2 inhibitors (SGLT2i) or Glucagon-Like Peptide 1 Receptor Agonist (GLP-1 RA) in patients with Type 2 Diabetes Mellitus (T2DM) and established Atherosclerotic Cardiovascular Disease (ASCVD) or Chronic Kidney Disease (CKD) for its cardiovascular benefits. Methods: Our retrospective study analyzed data from 511 T2DM patients who visited the outpatient clinic between 7/1/22 to 6/30/23. Using Microsoft Excel, we assessed adherence to ADA guidelines by collecting data for SGLT2i, GLP-1 RA and statin prescriptions, urine microalbumin creatinine ratio measurements, and appropriate management of albuminuria. The study also investigated patients on dipeptidyl peptidase-4 inhibitors (DPP-4i) who were eligible for SGLT2i or GLP-1 RA. Results: Out of the 511 patients, 478 were eligible for SGLT2i or GLP-1 RA, and only 60% were prescribed these medications. Out of 479 patients eligible for statin prescription, only 85% were on it. Albuminuria was appropriately managed in 76% of eligible patients with Angiotensin-Converting Enzyme Inhibitors (ACEI) or Angiotensin II Receptor Blockers (ARBs). Additionally, 8 out of 11 patients on DPP-4i were eligible for SGLT2i or GLP-1 RA. Conclusion: We concluded that 60% of the patients eligible for SGLT2i or GLP-1 RA were prescribed the medication in our outpatient settings. The barriers identified were issues with insurance prior authorization and knowledge gaps. We aim to improve adherence to guidelines through multifaceted education strategies combined with audits and feedback. References:Diabetesjournals.org/care/article/46/Supplement_1/S158/148038/10-Cardiovascular-Disease-and-Risk-ManagementMarso SP, Daniels GH, Brown-Frandsen K, et al. Liraglutide and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2016;375:311-322. Marso SP, Bain SC, Consoli A, et al. Semaglutide and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2016; 375:1834-1844Gerstein HC, Colhoun HM, Dagenais GR, et al. Dulaglutide and cardiovascular outcomes in type 2 diabetes (REWIND): a double-blind, randomised placebo-controlled trial. Lancet 2019;394:121-130 Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. N Engl J Med 2015;373:2117-2128Wiviott SD, Raz I, Bonaca MP, et al. Dapagliflozin and cardiovascular outcomes in type 2 diabetes. N Engl J Med 2019;380:347-357

Presentation: 6/3/2024
7056 Can ChatGPT Educate Multicultural Patients About Metabolic Syndrome?
Authors: Wu Gloria , Cheng Emily , Toram Viki V , Rosen Kyler , Wong Adrial , Zhao Weichen , Del Buono Milan
Published: October 2024

Disclosure: G. Wu: None. E. Cheng: None. V.V. Toram: None. K. Rosen: None. A. Wong: None. W. Zhao: None. M. Del Buono: None.

Background: Metabolic Syndrome, which affects Asians, is a major risk factor for diabetes. According to the National Institute of Health (NIH), 1 in 3 Americans have Metabolic Syndrome. Diabetes affects 30 million Americans, and 8 million more are undiagnosed. ChatGPT and Bard are Artificial Intelligence (AI) mediated LLMs launched on 11/30/2022 and 3/21/2023, respectively, that generate real-time conversational responses. Purpose: Can ChatGPT educate our multicultural patients about metabolic syndrome? Methods: 1. User prompt into ChatGPT and Bard: What is metabolic syndrome? I am a South Asian male, 40 years old, with a cholesterol level of 250 and a fasting blood sugar level of 120. The exact prompt was used with an Asian male as a substitute. 2. The prompt was translated into Telugu, Hindi, Simplified Chinese, and Traditional Chinese via Google Translate. 3. Flesch-Kincade (FK) method of ascertaining reading level was used. FK is used by the US Department of Education. Results: Flesch-Kincaid reading ease: ChatGPT: English=29.2, Telugu=60.1, Hindi=33.4, Chinese (Trad.)=14.5, Chinese (Simp.)=22.6 Bard: English=35.3, Telugu=52, Hindi=51.7, Chinese (Trad.)=52, Chinese (Simp.)=36.8 Language Group Comparison to English: ChatGPT: Indian Languages p=0.004; Chinese Languages p=0.081. Bard: Indian Languages p=0.007; Chinese Languages p=0.136. Of note, the Telegu response has one incorrect response. Conclusions: In conclusion, ChatGPT and Bard can provide factual responses based on English prompts. Foreign prompts can yield inaccurate information. Physicians and their teams still need to supervise patient usage.

Presentation: 6/2/2024
5066 Evolution And Evaluation Of A Longitudinal ECHO Program In Transgender Health
Authors: Rothman M S , Chippone A , Clark A , Saxon D , Miller D , Young K , Iwamoto S J
Published: October 2024

Disclosure: M.S. Rothman: None. A. Chippone: None. A. Clark: None. D. Saxon: None. D. Miller: None. K. Young: None. S.J. Iwamoto: None.

Background: Providers often report a lack of training in the care of transgender and gender diverse(TGD) patients. Extension for Community Healthcare Outcomes(ECHO) programs have been developed around the world as a form of tele-mentoring. As gender-affirming care bans rise in the US, it is crucial for providers to have access to education in TGD patient health. ECHO Colorado(CO) launched “Comprehensive Care for Transgender Patients” in 2020 as an ongoing live monthly series for providers interested in improving care for TGD patients. Design/Methods: 40 sessions were held between 2/2020-9/2023. Topics spanned mental health, medical, and surgical care with didactic presentations followed by case discussions. Demographic data was collected at registration via Connect, an online portal, and evaluations were conducted quarterly using Qualtrics. Not all questions were required. Participants attending at least one session in the quarter were eligible to complete the survey. With multiple responses, the most recent survey was used in the analysis. Results: 257 individuals participated in at least one session. 164/255 (64.3%) respondents identified as clinical health care providers. The majority of the remainder identified as: behavior health professional(n=28), other(n=23) or health outreach/admin(n=17). Most participants (79.4%) practice in CO and the majority provide direct care for underserved populations. 110 attendees responded to at least one survey. 96% of all participants reported improved understanding of the subject matter. Of the prescribing providers, 80%(60/75) rated themselves as comfortable with continuing and 68%(51/75) were comfortable with initiating hormone therapy. In the most recent quarter, participants were asked to self-report levels of professional isolation before and after the series. 30%(8/27) reported feeling very or extremely isolated prior, while none(0/27) reported this since participating. Common barriers reported were obstacles to implementing care and scheduling conflicts preventing attendance. Conclusion: Participants with a variety of backgrounds are highly satisfied with this longitudinal program. ECHO learning may combat feelings of professional isolation. The majority of providers report comfort with initiating and providing hormone therapy, but future efforts should seek ways to improve comfort, competency and examine asynchronous educational opportunities. Interest from attendees outside of CO supports a need for a national collaborative of TGD focused ECHOs.

Presentation: 6/1/2024
8006 Feedback For Fellows: Opening The Pandora's Box Of "Confidence" In Feedback
Authors: Ananthakrishnan Sonia , Noronha Craig
Published: October 2024

Disclosure: S. Ananthakrishnan: None. C. Noronha: None.

Background: Feedback is a key component of training at any level. Sub-specialty fellowship training has unique goals and barriers to feedback exchange, such as faculty tension with giving negative feedback to potential future colleagues, that are uncommon in other training environments. A common characteristic that may be discussed in feedback exchanges is a supervisor’s perception of a trainee’s confidence. Concerns have been raised both at the local and national level regarding the potential negative effects of the word “confidence” in medical education, due to cultural, gendered, and racial biases, which can be harmful to the learning environment in endocrinology where many trainees hail from diverse geographic and cultural backgrounds. Methods: Within our institution, ACGME annual survey data between 2015-2019 indicated that a large portion of internal medicine specialty fellows were not satisfied with the feedback they received. Pilot data from a survey administered to trainees in the Department of Medicine at our institution indicated that 66.67% (n=31) of trainees had received feedback about their confidence level as observed in the clinical setting. Over 70% of those trainees felt the feedback was actionable less than half the time. The themes of frustration and ambiguity in interpreting the feedback around “confidence” emerged from the trainee data. To address perceived deficiencies in supervisor knowledge, skills and attitudes around fellowship-specific feedback exchange, we implemented departmental workshops focused on highlighting tools related to giving feedback to fellow trainees and case-based discussions to understand how and why the word “confidence” is used in feedback and how it may be interpreted by trainees. Results: This feedback workshop has been instituted within our Department of Medicine and was piloted with a focus on fellowship education in the Endocrinology section by the time of this abstract (further data forthcoming). Following the workshop, attendees (n=13) were surveyed. 76.9% of respondents had experience delivering feedback with the word or theme of “confidence”, despite 69.2% of respondents being aware of the varied meanings of the word. Following the workshops, data from faculty attendees indicated 92% of respondents were aware of the varied meaning and 99% felt more comfortable using behavioral-based, as opposed to personality-based, language to support actionable changes in fellow skills. Conclusions: This workshop curriculum suggests further need to explore the impact of the word “confidence” in feedback exchanges. Our pilot data is a call to action for further research on the development of effective strategies on how to move past use of the word “confidence” in feedback, with the goal of providing more specific, bias-free and behavioral-based feedback that can support a more inclusive learning environment for fellowship trainees.

Presentation: 6/3/2024
7244 Kidney Donors With Metabolic Syndrome Have Increased Risk For Chronic Kidney Disease
Authors: Martínez-Franco Cybelle Daniela , Gomez-Perez Francisco J , Vilatobá Mario , Flores-Cárdenas Romina , Cuevas-Ramos Daniel
Published: October 2024

Disclosure: C.D. Martínez-Franco: None. F.J. Gomez-Perez: None. M. Vilatobá: None. R. Flores-Cárdenas: None. D. Cuevas-Ramos: None.

Kidney Donors with Metabolic Syndrome Have Increased Risk for Chronic Kidney Disease Introduction: Metabolic syndrome (MetS) has a prevalence of 56% in Mexico, been a common cause of progressive deterioration of renal function. Renal donors usually have good health at the time of donation, but some cases already present MetS or develop it over time. Objective: to evaluate the risk of MetS on chronic kidney disease (CKD) in kidney donors. Methods: we performed a comparative, longitudinal, observational and prolective study at a tertiary care hospital from 1980 to 2023. MetS was defined with ATPIII criteria. Renal function was assessed with the CKD-EPI formula to obtain the eGFR prior to the date of transplantation and at last follow-up. Student's t test, chi-square test, Kaplan-Meier, and multivariate Cox regression analyses were performed to assess the independent risk of MetS on renal function. Results: A cohort of 406 patients was collected, 283 cases (58% women), where 96 (34%) showed MetS criteria, and 187 (66%) without them used as control. There was no significant baseline difference on CrCl before donation between control group (97±19 ml/min) vs. MetS group (95±17 ml/min, p=0.45). The median follow-up was 25 (20.2-29.7) years. To assess the outcome of CrCl <60 mL/min, 4 groups were analyzed according to their MetS status at baseline - last follow-up. The fastest decreased on CrCl was seen at group 3 (No MetS - With MetS) after 17 (95%CI 14-19) years of follow-up, then group 4 (MetS - MetS) after 19 (3-34) years, followed by group 2 (With MetS - No MetS) with 23 (10-35) years, and finally group 1 (No MetS - No MetS), after 27 (23.7-30.5) years (p<0.0001). Group 1 was taken as reference to calculate CKD risk between groups. MetS showed a statistically significant risk as an independent determinant for CKD at follow-up with a HR=1.6 (0.7-3.3, p=0.21), HR=2.9 (1.2-7.0, p=0.01) and HR=2.2 (1.1-4.4, p=0.02) for group 2, 3 and 4, respectively. Conclusions: Having or developing MetS on kidney donors caused significantly higher risk of presenting CKD at last follow-up. Clinicians should be aware of such risk to implement strategies for prevention and treatment of MetS, with close and chronic surveillance of such patients.

Presentation: 6/1/2024
9182 Metastatic Extra-Gastrointestinal Stromal Tumor Presenting As Hypoglycemia
Authors: Faour Omar , John Dieula , Suryanarayanan Sowmya K , Rizvi Ali A
Published: October 2024

Disclosure: O. faour: None. D. John: None. S.K. Suryanarayanan: None. A.A. Rizvi: None.

Introduction: Non islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome seen in association with solid abdominal tumors of mesenchymal and epithelial origin. We report a case of metastatic extra-gastrointestinal stromal tumor (E-GIST) presenting with severe hypoglycemia as its initial manifestation. CASE DESCRIPTION: A 46-year-old patient was found to have a blood glucose of <45 mg/dl during a routine clinic visit with her primary care physician. Although she was asymptomatic, she was sent to the emergency room (ER) for further evaluation. She had a history of prediabetes managed by lifestyle modification. She has been experiencing multiple episodes of hypoglycemia previously which fulfilled the Whipple’s triad in the preceding months. These hypoglycemic episodes included loss of unconsciousness, falls in the shower with head injury, and several hospital visits. Serum glucose in the ER was 14 mg/dl and hypoglycemia persisted despite continuous dextrose solution. Physical examination was notable for a distended, non-tender abdomen and cervical lymphadenopathy. CT scan showed a 15 cm mass in the liver, multiple large masses in the mesentery, and a 11 cm lesion in the left pelvis. There were enlarged lymph nodes in the abdomen, chest, and neck. Serum chemistries drawn when the patient was hypoglycemic revealed potassium level of 2.7 mg/dl (3.5-5.5) an insulin level of <1.0 mIU/L (5-25), C-peptide <0.1 ng/mL (0.5-2), cortisol 13.8 mcg/dL (5-25), and insulin-like growth factor-2 (IGF-2) was 270 ng/mL (38-267). The IGF-2/IGF-1 molar ratio was 3.4 (normal <3:1). The sulfonylurea drug screen came back negative. Upper and lower endoscopies were unrevealing. Biopsy of the liver lesion showed cytology and immunohistochemical findings consistent with a epithelioid metastatic extra-gastrointestinal stromal tumor. A provisional diagnosis of NICTH was made. The patient responded well to intravenous glucose, oral carbohydrate intake and high-dose corticosteroids. She was subsequently started on therapy with the tyrosine kinase inhibitor (TKI) imatinib. Discussion: Paraneoplastic hypoglycemia is often seen in association with metastatic epithelial and mesenchymal tumors. IGF-2 and incompletely processed pro-IGF-2 activates autocrine, paracrine, and endocrine pathways that lead to tumor growth, fasting hypoglycemia, rarely of acromegalic features. Treatment with octreotide, diazoxide, and glucagon is generally ineffective, while glucocorticoid use and surgical intervention are helpful in ameliorating the hypoglycemia. Tumor-directed therapy with TKIs, primarily imatinib, appears promising in achieving remission. Our case is a clinical reminder that hypoglycemia secondary to NICTH can be the predominant presenting feature in patients with underlying E-GIST.

Presentation: 6/3/2024
7747 Poor Sleep Health And Shift Work Are Modifiable Risk Factors For Chronic Kidney Disease In UK Biobank Participants
Authors: Kanki Monica , Xiang Ruidong , Artika Nath , Nikolic-Paterson David , Tesch Gregory H , Takeuchi Fumihiko , Young Morag Jennifer
Published: October 2024

Disclosure: M. Kanki: None. R. Xiang: None. N. Artika: None. D. Nikolic-Paterson: None. G.H. Tesch: None. F. Takeuchi: None. M.J. Young: None.

Evaluating the impact of lifestyle factors and work practices on renal function has the potential to support the early prevention of chronic kidney disease (CKD). Current studies linking disrupted circadian rhythms to the development or progression of CKD are limited and show disparate findings. In this study, we aimed to investigate associations between circadian rhythm-disrupting behaviours and markers of renal function in a population-based cohort using the UK Biobank database (>390,000 European White adults). We compared estimated glomerular filtration rate (eGFR), urine albumin-to-creatinine ratio (UACR), blood creatinine and blood urate levels between short (<5-6hr), normal (7hr) or long (8->9hr) sleep lengths, in subjects assigned healthy (4-5), moderate (2-3) or poor (0-1) sleep quality scores, and subjects with different shift work schedules. History of hypertension, diabetes, cardiovascular disease, AKI, and CKD was lowest in subjects sleeping 7 hrs/day, in participants with healthy sleep quality, and in those who did not undertake shift work. Using multiple linear regression analyses, we identified an inverse U-shaped relationship between sleep length and eGFR after adjusting for key covariates including biological sex, age, and BMI in the baseline model. Sleep quality score was positively associated with eGFR, and negatively associated with blood urate. When stratified according to inflammatory status, biological sex, or age, this positive association between sleep quality and eGFR was lost in males and those with low or medium C-reactive protein (CRP) levels but remained significant in both age groups (≤50 years and >50 years old). In contrast, sleep quality was negatively associated with UACR in participants with medium CRP levels, above 50 years old, or separately in males only. Investigating associations between sleep length, shift work schedules, and other sleep-related factors (e.g. chronotype, daytime napping, and insomnia) with renal function is in progress. This study is the first to link associations between sleep quality and renal function to inflammatory status. We also show that compromised sleep health can affect renal function differently between males and females and is dependent on age. To date, our findings support promoting healthy sleep quality as a modifiable risk factor of renal dysfunction, which could be valuable in the prevention of CKD.

Presentation: 6/1/2024
7947 Semaglutide Induced Pancreatitis: A Case Report
Authors: Altaweel Tamara , Mathew Anoopa , Chalasani Pranav , Lawrence Lima , Hussain Shahed , Aldaoud Nour
Published: October 2024

Disclosure: T. Altaweel: None. A. Mathew: None. P. Chalasani: None. L. Lawrence: None. S. Hussain: None. N. Aldaoud: None.

Introduction/Background: As semaglutide (GLP1 RA) has become a cornerstone in diabetes and weight management, there have been studies indicating pancreatic inflammation with GLP1 RA use. We report a case of acute necrotizing pancreatitis secondary to semaglutide use.Clinical Case: A 52 year old male with a history of hypertension, morbid obesity with BMI of 40 kg/m2, alcohol induced pancreatitis presented to the hospital complaining of epigastric pain. On presentation, he appeared in distress due to pain but was hemodynamically stable. Physical examination revealed a moderately distended abdomen, tender to palpation over the epigastric area without guarding, and negative Murphy’s sign. The patient reported no alcohol consumption, tobacco usage, or recent abdominal injuries. Laboratory workup revealed elevated WBC 14.6 thous/mcL (4.5-10.5) and lipase 1941 U/L (<60). Abdominal ultrasound showed common bile duct 2 mm without gallstones and CT abdomen revealed acute pancreatitis with suspected necrosis in the pancreatic head and the pancreatic tail. Patient was started on aggressive fluid hydration, pain management and admitted to intensive care. Patient reported that he was started on semaglutide three months ago for weight management by his primary care physician. Patient improved symptomatically with pain control and tolerated oral intake. He was discharged home with recommendations not to resume semaglutide. Conclusion: Semaglutide involves direct stimulation of GLP-1 receptors in pancreatic cells, potentially leading to cell overgrowth, increased pancreatic weight, duct occlusion and inflammation. Despite the SUSTAIN-6 trial indicating no increased risk of acute pancreatitis in diabetic patients using semaglutide, atypical presentations of pancreatitis are noted in patients using the medication for weight management. When all identifiable causes of pancreatitis are eliminated, semaglutide-induced pancreatitis should be a primary consideration in the differential diagnosis. Physicians should exercise caution and give careful consideration when prescribing semaglutide for weight management in patients with conditions that increase risk for pancreatitis.

Presentation: 6/2/2024
8687 The Efficacy of GLP1 Receptor Agonists in Obese Women with PCOS in Promoting Weight Loss and Hormonal Regulation: A Systematic Review and Meta-Analysis
Authors: Morais B Austregesilo Athayde H , Prizão V M , Ximenes Mendes B , Defante M L , Martins O C , Correa T L , De Moura de Souza M d
Published: October 2024

Disclosure: B. Austregesilo Athayde H Morais: None. V.M. Prizão: None. B. Ximenes Mendes: None. M.L. Defante: None. O.C. Martins: None. T.L. Correa: None. M.D. De Moura de Souza: None.

Background: GLP1 receptor antagonists (GLP1a) are known for their efficacy in promoting weight loss among obese and diabetic patients. However, their impact on weight reduction and hormonal regulation in obese females with polycystic ovarian syndrome (PCOS) remains understudied. Therefore, we aimed to perform a meta-analysis exploring the efficacy of GLP1a against placebo for ameliorating symptoms of PCOS. Hypothesis: The use of GLP1 receptor agonists in obese women with PCOS reduces body mass index and waist circumference as well as normalizes hormone levels such as total testosterone, total cholesterol, and HOMA-IR. Methods: We conducted a comprehensive search of PubMed, Cochrane, and Scopus databases to identify trials comparing GLP1a against placebo among women diagnosed with PCOS based on the Rotterdam Criteria. Our primary outcomes of interest included body mass index (BMI), triglycerides, waist circumference, total testosterone, total cholesterol, and HOMA-IR. We performed data extraction and quality assessment for studies that met the inclusion criteria. Subsequently, we conducted a statistical analysis using Review Manager 5.1.7 (Cochrane Collaboration). We evaluated heterogeneity using I² statistics. Results: We included 176 participants from 4 studies, which all were RCTs. GLP1a was used to treat 111 (63.06%) patients. Analyzed outcomes included waist circumference (MD: −5.16 cm; 95% CI: −6.11 to −4.21; p < 0.00001), total testosterone (MD: −1.33; 95% CI: −2.55 to −0.12; p =0.03), BMI (MD: -2.42; 95% CI: -3.10 to -1.74; p < 0.00001), total cholesterol (MD: −0.04; 95% CI: −0.10 to 0.01; p =0.15), HOMA-IR (MD: −0.30; 95% CI: −0.92 to 0.32; p =0.35), Triglycerides (MD: −0.20; 95% CI: −0.30 to −0.11; p < 0.00001) were lower in patients treated with GLP1a compared with placebo. Most patients who discontinued the trials did so because of a nausea side effect. Conclusion: The utilization of GLP1a demonstrates efficacy in reducing body mass index (BMI), triglycerides, waist circumference, total testosterone, total cholesterol, and HOMA-IR. These results signify its viability as a favorable treatment option for managing PCOS in obese females.

Presentation: 6/3/2024
8536 Unusual Finding of Familial Adenomatous Polyposis in a Patient with X Linked Adrenoleukodystrophy
Authors: Deswal A , Dwarakanathan A
Published: October 2024

Disclosure: A. Deswal: None. A. Dwarakanathan: None.

Introduction: X Linked Adrenal Leukodystrophy (X-ALD) is a rare hereditary genetic disorder of impaired peroxisomal metabolism due to a defective transmembrane protein, ADLP. Defective ADLP impairs transport of VLCFA-CoA esters across cytosol into peroxisomes leading to build-up of toxic VLCFA in the cells. X-ALD is caused by mutation in ABCD1 gene, located on X chromosome, which codes for ADLP. It has a broad clinical spectrum including Cerebral ALD, Adrenomyeloneuropathy and Adrenocortical insufficiency. X-ALD has a general prevalence of 1 in 17,000 newborns. Approximately 80% of males with X-ALD develop primary adrenal insufficiency in their lifetime. It can be diagnosed by measuring VLCFA levels in plasma , checking for ABCD1 gene mutation or by doing Brain MRI (depending upon phenotypical presentation ). Case presentation: We report a case of a 23 year old man who had primary adrenocortical insufficiency subtype of X-ALD. His mother was a carrier of ABCD1 gene mutation. He himself tested hemizygous for ABCD1 gene. He came to our office for a follow up visit after an episode of adrenal crisis for which he was hospitalized. He was started on replacement therapy with prednisone and fludrocortisone. Over the next couple of years, he was diagnosed with diabetes mellitus with initial HbA1C of 8.8%. GAD antibody test for type I DM came out negative. His diabetes was managed with metformin and pioglitazone( later discontinued) .By the age of 25,he was found to have polyposis of colon. He tested positive for APC gene mutation . He underwent a J pouch surgery . He also developed PICA aneurysm. Discussion: X-ALD is a hereditary progressive disease with no association between genetic and phenotypic presentations. Adrenal insufficiency type is usually the first to present. Cerebral ALD is typically diagnosed between the ages of 3-18 presenting as psychiatric illness. Myelopathy typically starts by middle age and involves the spinal cord, causing the affected individuals to develop gait disturbances , bladder and bowel dysfunction, with severe mobility dysfunction by 5th-6th decade of life. We present a unique case of a young man with adrenal insufficiency type of X-ALD who also developed gastrointestinal pathology. Per our literature review, X-ALD has not been seen associated with APC gene mutations or colon carcinomas . Pathology behind XLD revolves around ABCD1 gene mutaion causing VLCFA accumulation in plasma, fibroblasts, adrenal glands, oligodendrocytes , astrocytes etc. Whereas FAP involves APC gene mutation which affects the intestinal epithelial cells leading to their apoptosis and polyp formation. X-ALD and FAP are disorders of two different gene mutations with varied clinical presentations. But the question arises regarding finding of APC gene mutation in a patient with ABCD1 gene mutation that if it is a mere co-incidence or common mutation pathway linking these two disorders exists.

Presentation: 6/2/2024