bluuebunny/crossref_metadata_2025 huggingface dataset:
SUN-696 Effect of Night Shifts on Glycemic Variability in Patients with Type 2 Diabetes
Authors: Garieva Mayya Akakievna
Published: May 2020

The analysis of indicators of carbohydrate metabolism and variability of glycemia in patients with type 2 diabetes mellitus working in night shifts was carried out. As model patients with impaired circadian rhythm, the study included 34 patients, railway transport drivers, with shift mode and the presence of night shifts, with work experience of more than 5 years, the duration of type 2 diabetes mellitus (DM2) from 1 to 7 years, who are on oral therapy with hypoglycemic drugs. Simulation of different working conditions (day-night) was carried out in the simulator “driver’s cabin”. All patients underwent a study of the main indicators of carbohydrate metabolism (fasting glycemia, postprandial glycemia, glycated hemoglobin (HbA1c)), as well as continuous daily glucose monitoring (CGMS) using Medtronic MiniMed iPro2 system (from 3 to 7 days).

Target glycemic levels were not achieved: fasting glycemia was 6.98±1.41 mmol/l; postprandial glycemia was 9.57±1.65 mmol/l; HbA1c was 7.23±1.62%.

The analysis of CGMS revealed high variability of glycemic index MAGE-4.88±0.59 mmol/l. also calculated indicators SD - 1.52±0.63 mmol/l; Conga - 3.17±0.54 mmol/l; MODD - 2.27±0.12 mmol/l.

The period of hyperglycemia (glucose value above 7.8 mmol/l) according to the results of CGMS was 43.5% (min 19-max 56). The duration of hypoglycemic States in patients without night shifts was 2.4% within 24 hours (min 0-max 6.6).

Correlation analysis between carbohydrate metabolism and glucose variability revealed a significant strong relationship between the level of postprandial glycemia and modd (r=0.87, P=0.001) and MAGE (r=0.82, P=0.01), and also established a mean significant correlation between the level of postprandial glucose and Conga (r=0.52, P=0.01) and SD (r=0.61, P=0.05).

Fasting glycemia and congas were moderately correlated (r=0.4, P=0.01).

Weak reliable correlation was found only between HbA1c level and Conga variability index (r=0.27, P=0.04).

Conclusions: the results of the study indicate the lack of adequate glycemic control in persons working night shifts, high variability of glycemia, which is an independent risk factor for cardiovascular disease in patients with DM2. The associative relationship of fasting glycemia and postprandial with the indicator of variability Conga shows that glucose fluctuations during the day in patients are constant.
SUN-425 Indiscriminate Thyroid Function Testing on Acute Hospital Admissions Reveals a High Abnormality Rate Requiring Follow Up
Authors: McEvoy Robert P , O’Riordan Anthony , Hannon Mark J
Published: May 2020

The population attending the Medical Assessment Unit at our hospital comprises patients attending electively for investigation and acutely unwell patients presenting for unscheduled care. The standard panel of blood tests taken on arrival includes thyroid function tests (TFTs, i.e. TSH and free-T4), despite a recent review questioning the clinical utility of this practice [1]. We performed a retrospective audit to determine what proportion of our patients had abnormal thyroid function on presentation, and whether these abnormal test results were being followed up.

Using the iSoft Clinical Manager software, a list was generated of all patients who attended the hospital between January 2018 and June 2018 inclusive. For each attendance, we recorded the date, medical record number, patient age, gender, and TFT result. Abnormal TFT results were classified as overt or subclinical hyper- or hypothyroid, or non-thyroid illness syndrome (NTIS), based on their admission TSH and free-T4. We then examined the hospital and primary care records of patients with abnormal TFTs to determine if they had ongoing thyroid follow up post discharge.

In total, 2,298 patients attended over the 6-month study period. The mean patient age was 67.2 years, and 49% were female. Thyroid function tests were ordered on the day of attendance for 1,688 patients (73%). Of these, 181 results (11%) were abnormal: 20 overt hyperthyroid (11%), 72 subclinical hyperthyroid (40%), 12 overt hypothyroid (7%), 35 subclinical hypothyroid (19%), and 42 NTIS (23%). Twenty of these patients died within 3 months of the abnormal TFT result (4 overt hyperthyroid, 3 subclinical hyperthyroid, 3 overt hypothyroid, 6 subclinical hypothyroid, and 4 NTIS). Of the remaining 161 patients, 74 (46%) had not been followed up within 3 months (4 overt hyperthyroid, 34 subclinical hyperthyroid, 3 overt hypothyroid, 15 subclinical hypothyroid, and 18 NTIS).

The low percentage of abnormal TFTs (11%) in this audit is in keeping with similar studies where thyroid function testing was performed on unselected hospital populations [1]. Subclinical hyperthyroidism was by far the most common abnormality found. A high percentage of abnormal tests (46%) were not followed up, with poor compliance with thyroid management guidelines [2]. Future work will investigate adoption of an ‘opt-in’ order system [3] and electronic alerts to flag abnormal results for follow-up.

[1] Premawardhana LD. Thyroid testing in acutely ill patients may be an expensive distraction. Biochemia medica. 2017; 27(2): 300-307.

[2] Ross DS et al. 2016 American Thyroid Association Guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016 Oct; 26(10):1343-1421.

[3] Leis B et al. Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study. BMJ Qual Saf. 2019; 28(10): 846-52.
SAT-465 Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis: Diagnosis or Distraction?
Authors: de Souza Tamara Gizelle , Bustos Mario Andres , Kargi Atil Yilmaz
Published: May 2020

In 1966 a case of episodic encephalopathy with anti-thyroid antibody (ATAb) positive Hashimoto’s thyroiditis was first reported. Controversy persists regarding Hashimoto’s encephalopathy, now known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) and any relationship with ATAb. There is no literature supporting an etiologic role of ATAb in SREAT. Nor has there been correlation shown between ATAb titer and severity of thyroid dysfunction or SREAT(1).

A 56 yo female was admitted to a community hospital three times with visual hallucinations and slurred speech. Brain MRI, LP and standard tests including C3/C4, folate, B12, ANA and ANCA were unrevealing. Thyroglobulin antibodies (TgAb) and anti-thyroid peroxidase antibodies (TPOAb) were positive. Diagnosed with SREAT with relief of symptoms on high dose IV corticosteroids. Discharged on oral prednisone. Seven months later she began experiencing progressive proximal weakness of all extremities associated with exertional dyspnea, fatigue and weight gain. EMG studies indicated steroid-induced myopathy of the proximal extremities. After prednisone tapering, she was admitted to our institution with acute confusion, blurred vision, fever, tachycardia, tachypnea and hypoxemia.

Examination showed Cushingoid features. Labs showed hyperglycemia, ANA (+), TPOAb (+), TgAb (+), low FreeT4, low T3, normal TSH and elevated IgG in the CSF. Brain MRI showed meningeal enhancement of parieto-occipital lobes and left tentorium. Empiric antibiotics started to cover infectious meningoencephalitis. Endocrinology consulted for iatrogenic Cushing’s syndrome with hyperglycemia, abnormal thyroid function tests (TFTs) with positive ATAb and evaluation for SREAT. We recommended tapering steroids and evaluation for infectious, autoimmune or paraneoplastic causes of encephalopathy, before presuming SREAT. Rheumatological and infectious work-up was negative. CT chest showed nodular densities and CT abdomen showed hepatic, splenic and right inguinal region masses. Biopsy of inguinal mass showed Diffuse Large B-cell Lymphoma confirmed on bone marrow biopsy. CSF flow cytometry was unrevealing, likely due to prior steroids. Leptomeningeal enhancement likely reflected leptomeningeal metastases. Treated with systemic R-CHOP, high dose MTX, intrathecal MTX, cytarabine and corticosteroid tapering. Complete remission was achieved with normalization of TFTs, resolution of her Cushingoid and encephalopathic features.

This case illustrates SREAT as a diagnosis of exclusion. ATAbs may be positive in non-thyroid autoimmune disorders, other neurological conditions and 10-20% of the general population (2). B cell lymphoma with leptomeningeal metastasis caused encephalopathic features which improved with corticosteroids. Ascribing a diagnosis of SREAT led to delayed cancer diagnosis and treatment.
SAT-618 Nattokinase to Improve Insulin Sensitivity and Weight Loss in Women with Obesity +/- Diabetes
Authors: Cobos Leopoldo M , Torre Yanira Sanchez-De La , Herbst Karen L , Beltran Karen
Published: May 2020

Background: Diabetes (DM) and obesity are related health issues which are increasing in prevalence. But not all obesity is related to DM. Women suffering from Lipedema are categorized as gynoid obese. Nattokinase (Natto) is an enzyme supplement that has been shown to degrade fibrin. Patients with obesity tend to have elevated clotting factors which can lead to adipose tissue hypoxia, impaired insulin signaling, and lead to insulin resistance. Research in fat disorders noted that fat biopsies from women with Lipedema likely had micro-clots, and patients with Lipedema treated with Natto reported a decrease in clothing size and fat distribution. Objective: Determine the effect of Natto on participants with Obesity and DM and in patients with Lipedema without DM. Materials and Methods: Group 1: Involved subjects with Obesity and DM. This was a double blinded, randomized controlled clinical trial over 3 months. A total of 17 female patients were recruited from a rural clinic. Nine received Natto 2,000 FU daily and eight received an identical placebo capsule daily. Fasting labs, questionnaires, bioimpedance, and anthropometric measurements were completed at Baseline and 3 months. Group 2: 42 women with Lipedema seen at a Fat Disorder Clinic. 21 received Natto and 21 did not. We compared for weight only from the day Nattokinase was started until follow-up, which varied from 4 months to 1 year 8 months. Results: Group 1: After 3 months, there was no difference in weight loss in both groups. Per Bioimpedance, more subjects lost water weight in the Natto group (63%) compared to Placebo (33%). More subjects in the Natto group had a decrease in HbA1c (43%) compared to Placebo (22%), with average decrease in the Natto group of 0.9%. Also, more subjects in the Natto group had lower fasting insulin levels (75% vs 22%), lower fasting glucose level (50% vs 22%) and lower HOMA index (63% vs 22%). Group 2: 57% of patients in the Natto group lost weight compared to only 33% of patients not on Natto. Conclusions: In participants with obesity and DM, regardless of weight loss, metabolic health improved after taking Natto for 3 months. Higher percentage of subjects in the treated group had improved HbA1c, fasting Insulin, glucose, and HOMA score. We hypothesize that if treatment time was beyond 3 months, further metabolic improvement would be noted, indicating that Natto could have potential as an adjunct to DM care. The difference in weight loss between Metabolic Obesity and Lipedema reflects the difference in adipose tissue, likely differing in etiology and pathophysiology. Further studies are needed to evaluate long term benefits of Natto, including larger and longer randomized controlled trials, and assessment of clotting factors.
SUN-029 Diabetes Mellitus Associated with Klinefelter Syndrome
Authors: Sarria Carolina , Yauri william lapa
Published: May 2020

Background: It has not been clarified why diabetes mellitus develops in patients with Klinefelter’s syndrome. However the association between both diseases is frequent. Clinical Case: A 31-years-old man with type 2 diabetes diagnosed 2 months ago who received metformin for treatment. He presented to the hospital with dysuria, polyuria, polydipsia, weight loss, hyporexia, vomiting and drowsiness. On examination: BP: 110/60 mmHg, HR: 108 lp, FR: 24 rp, T °: 37 ° C, BMI: 31.4 kg / m2, oral mucosa dry, bilateral gynecomastia, subcutaneous cellular tissue of gynecoid distribution. His body hair was thin. His penis was small and both testicles were prepubertal. Laboratory: Glucose: 410 mg / dl; HbA1c 15.2%; creatinine: 1.01 mg / dl; arterial gases: pH 7.14 pCO2: 20, HCO3: 6.6, AG: 29. Normal electrolytes. Ketonuria: 3+. We concluded: diabetic ketoacidosis. In addition, FSH 61.18 μU / ml (RR: 1.5-12.5); LH: 28.47 μU / ml (RR: 0.7-8.6); Total testosterone: 0.41 ng / ml (RR: 2.8-8), compatible with hypergonadotropic hypogonadism. Therefore a karyotype is requested in peripheral blood, resulting in 47, XXY in 20 metaphases analyzed. Klinefelter’s syndrome was diagnosed from his physical characteristics, hormonal findings and his chromosomal aberration. He received testosterone undecanoate every 4 weeks, NPH insulin 12 IU / 8UI plus metformin 850 mg every 12 hours. Three months later: baseline glucose 89 mg / dl and HbA1C of 9.5%. Conclusion: We present the case of a young male with diabetic ketoacidosis and hypogonadism, secondary to Klinefelter syndrome. Klinefelter syndrome is associated with Diabetes mellitus with a RR that varies from 1.64 to 7.06 according to current literature. In addition, we highlight the importance of the medical history and physical examination for an adequate diagnosis of rare conditions such as Klinefelter Syndrome. Reference: 1. Kanakis GA, Nieschlag E. Klinefelter syndrome: more than hypogonadism. Metabolism. Septembere 2018;86:135-44.
MON-507 A Descriptive Study of Clinical and Surgical Characteristics of Patients with Thyroid Cancer: A 10-Year Retrospective Study from UAE
Authors: Alnuaimi Abdulla Mohamed , Alameri Majid , Mustafa Huda , Khalil Aly Bernard
Published: May 2020

Introduction: Thyroid cancer is the sixth most common type of cancer in the UAE. It has been observed that the incidence of thyroid cancer has been steadily increasing worldwide. However, limited studies about thyroid cancer has been reported from the Arab gulf region.

Objective: The objective of this study was to describe the clinical and surgical characteristics of patients with thyroid cancer in the UAE population.

Methods: Retrospective analysis was performed on all adult patients attending thyroid cancer clinic at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi, UAE over ten years from 2008 to 2018. All patients with a confirmed histological diagnosis of thyroid cancer who had surgical intervention with long-term follow up data on cancer outcome have been included. Categorical variable analysis and descriptive analysis were used to identify factors associated with increased risk of developing thyroid cancer.

Results: Total number of 203 patients with confirmed diagnosis of thyroid cancer were included. Most of the patients were female (72.9 %, n=148). Mean age at the time of diagnosis was 40±13 years. Papillary thyroid carcinoma was the most common thyroid cancer observed (95.6%, n=194) followed by follicular thyroid carcinoma (2%), medullary thyroid carcinoma (1.5%) and mixed medullary-papillary (0.9%). Classical variant and follicular variant of papillary thyroid carcinoma were the two most commonly observed histological subtypes of thyroid cancer with prevalence of 54.7 % and 21.7 % respectively. 91.1% (n=185) of patients had total thyroidectomy and 8.9%(n=18) had hemithyroidectomy. Female gender has been observed to be associated with higher prevalence of thyroid cancer (OR 2.78, 95% CI 1.18–4.50, p=0.001). Smoking status did not show any significant association with developing thyroid cancer. Recurrent thyroid cancer was observed in 9.4%(n=19). Most of recurrence happened as local metastasis 89.5%(n=17). The mean time of recurrence was 24 months (range, 7–64 months).

Conclusions: Our data demonstrate that in the UAE population, papillary thyroid cancer is the most common type of thyroid cancer. Female gender is observed to be associated with higher risk of thyroid cancer. Recurrence rate of thyroid cancer noted to be 9.4%. Further studies are required to investigate factors associated with recurrence and cancer free survival rates.
MON-916 Pure Large Cell Neuroendocrine Carcinoma (LCNEC) of the Gall Bladder in a Patient with Down Syndrome - a Rare Case of an Aggressive Tumor of the Gall Bladder
Authors: Azmath Misbah , Dunbar Ashley , Siddiqui Imran
Published: May 2020

Background: Pure large cell neuroendocrine carcinoma of the gall bladder (LCNEC-GB) is an extremely rare entity, with only 12 such cases reported in literature to date. None has been reported in a patient with genetic disorders. We describe the case of a patient with pure LCNEC-GB in the presence of Down syndrome and prior biliary atresia.

Case:

A 49-year-old female with Down Syndrome and history of neonatal surgery for congenital duodenal atresia presented with fever, vague abdominal discomfort and 6 month history of 15 pound weight loss. CT abdomen revealed a 5 X 4.2 cm exophytic, heterogeneously enhancing mass in the gall bladder fossa extending into segment 4B-5 of liver with mild intrahepatic biliary dilation, along with a 9 cm cystic lesion in continuity with the duodenum which was confirmed to a dilated duodenal anastomosis (from prior biliary surgery) on endoscopy. There was high suspicion for malignancy (gall bladder carcinoma versus intrahepatic cholangiocarcinoma) and subsequent metastatic workup including tumor markers, staging CT chest, MRI of the abdomen and diagnostic laparoscopy was negative.

The patient underwent robotic converted to open en bloc resection of the gallbladder mass with segment 4B-5 liver resection and adherent loops of small bowel as well as resection of the dilated duodenal anastomosis followed by reconstruction with a gastrojejunostomy and Roux-en-Y/small bowel entero-enterostomy and closure of duodenotomy.

Pathology demonstrated poorly differentiated “pure” large cell neuroendocrine carcinoma (G3), 6 cm in greatest dimension, with invasion of liver, duodenum and stomach, negative liver and gastric/small bowel margins. Lymphovascular invasion (LVI) was present with no perineural invasion (PNI), and 3/15 lymph nodes involved. Staging was determined to be pT4pN1.

Patient was considered for adjuvant chemotherapy based on few case reports (platinum/etoposide) but unfortunately developed systemic complaints of fevers, fatigue, pain in bones and joints 2 months post operatively. Workup revealed metastatic disease which was confirmed on biopsy. Several small satellite liver lesions were also identified which was consistent with metastatic hepatic disease. Patient and family elected to proceed with hospice. Patient died within 4 months of surgery.

Conclusion:

Pure LCNEC-GB is an extremely rare and aggressive tumor with a poor prognosis as seen in our patient. This is the first reported case of pure LCNEC-GB in a patient with a genetic syndrome, although it is unknown if it had any causal relationship with the tumor. Prior biliary atresia/post -surgical inflammation may have also contributed to its pathogenesis by plausible development of metaplasia and expression of neuroendocrine cells which are normally absent in the gall bladder. Our case might help shed some light into pathogenesis and genetic basis if any of this rare entity.
MON-678 Worsening Diabetes Control in Breast Cancer Patients Treated with Alpelisib
Authors: Geier Robert , Al Hommos Nisreen Abu , Nyenwe Ebenezer A , Eapen Anita
Published: May 2020

Introduction: A new phosphatidylinositol-3-kinase (PI3K) inhibitor, alpelisib (Piqray) has been recently approved for the treatment of breast cancer. Severe hyperglycemia has been reported as an adverse effect. Many breast cancer patients also have diabetes mellitus type 2 which puts them at a higher risk for this adverse effect.1 2

Case description: Patient is a 73 year old Caucasian woman with history of insulin treated type 2 diabetes mellitus and breast cancer who presented to the hospital with a left hip fracture. She has been recently started on alpelisib with worsening glycemic control. Glycemic control improved after alpelisib was held for 5 days. She resumed taking alpelisib and had an up titration of the insulin regimen. During her hospital stay, she suffered from hyperglycemia as high as 558 mg/dl. HbA1c increased to 11.3% from 6.5% reportedly before starting alpelisib. Patient was discharged on an intensified regimen with close follow up.

Discussion: Alpelisib is a PI3K inhibitor used in the treatment of postmenopausal women and men with hormone receptor positive, human epidermal growth factor receptor-2 negative, PIK3CA-mutated metastatic breast cancer. It inhibits PI3K which in turn inhibits protein kinase B (AKT). Insulin binds to insulin receptor substrates which activates PI3K, which in turn activates AKT resulting in translocation of the glucose transporter GLUT4 to the plasma membrane causing an uptake of glucose.3 A disruption in this pathway will result in hyperglycemia. Hyperglycemia was reported in 65% of patients with some cases found to be in ketoacidosis. This adverse effect means frequent monitoring of blood glucose is required following initiation of this treatment.4

Conclusion: Alpelisib is a new drug used in the select treatment of breast cancer. It can cause severe hyperglycemia and potential worsening of diabetes. Blood glucose should be monitored closely in patients with diabetes who are treated with alpelisib.

References:

Giovannucci E et al. Diabetes and Cancer. A consensus report. Diabetes Care 33:1674–1685, 2010.

Boyle P et al. Diabetes and breast cancer risk: a meta-analysis. British Journal of Cancer 107, 1608–1617, 2012.

Huang, X et al. The PI3K/AKT pathway in obesity and type 2 diabetes. International Journal of Biological Sciences14,1483–1496,2018.

Piqray [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp;2019
MON-290 Ipilimumab Immune-Related ACTH Deficiency Is of Acute Onset and Severe
Authors: Seejore Khyatisha , Giannoudi Marilena , Osborn Djoah , Lynch Julie Marie , Dunwoodie Elaine , Hook Jane , Marples Maria , Murray Robert Douglas
Published: May 2020

Introduction

Immune checkpoint inhibitors (ICIs) are immunomodulatory molecules that downregulate T-cell inhibiting-receptors or ligands to promote an enhanced anti-tumour response. Ipilimumab is a human monoclonal antibody directed against cytotoxic T-lymphocyte antigen-4 (CTLA-4) that has been shown to significantly improve survival in patients with metastatic melanoma. Immune-related adverse events (irAEs) occur in some patients with increased T-cell activation, of which ipilimumab-related hypophysitis (IH) is an important endocrine complication. The aim of this study is to determine the incidence of IH and characterise clinical presentation and outcomes in these patients.

Patients and Methods

We retrospectively evaluated consecutive adult patients with melanoma treated between December 2010 and August 2019 at a tertiary cancer centre. All patients received ipilimumab (3mg/kg) monotherapy or in combination with PD-1 (programmed cell death protein 1) inhibitors (nivolumab or pembrolizumab). Symptoms, pituitary hormone assessment, pituitary imaging and patient survival were assessed.

Results

Of 189 patients, 23 patients (12.2%, 13 male; age 59.2±11.8 years) presented with hypophysitis, two having received ipilimumab monotherapy. The median onset was at 17.3 weeks (range: 6.7-160 weeks) after treatment start, occurring in 57% after the fourth infusion (n=13). Five patients developed late-onset IH (range: 30.1-160 weeks) whilst on treatment with PD-1 inhibitors. Three of the patients developing hypophysitis (13%) received only a single ipilimumab infusion. Additional irAEs were diagnosed in 16 patients (70%) with IH, including six cases of destructive thyroiditis and one of autoimmune diabetes.

The main presenting symptom of IH was lethargy (n=18, 78%) followed by headache (n=8, 35%). Corticotroph deficiency with cortisol levels <83 nmol/l (<3μg/dL) at presentation were observed in all patients. At diagnosis, a drop in cortisol level of >70% over a median time of 22 days (range: 3-39 days) was evident in 87% patients. A fall in fT4 level of at least 20% from baseline was observed in ten patients (59%, 10/17 – after excluding patients with thyroiditis) at a median of 4 weeks (range: 0-8 weeks) prior to the diagnosis of IH. Gonadotroph deficiency was detected in three male patients.

At the end of follow-up (median 14.3 months, range: 1-61.5 months after IH diagnosis), corticotroph deficiency was persistent in all patients; seven of ten patients recovered thyrotroph function and gonadotroph deficit resolved in one patient. Three patients with hypophysitis died within the first year of immunotherapy.

Conclusion

The incidence of IH was 12.2%, predominantly occurring after the fourth infusion. IH is characterised by acute severe drop in cortisol levels to less than 3μg/dL. A falling fT4 may herald development of ACTH deficiency.
SAT-571 Rare Case of Tocilizumab-Induced Severe Hypertriglyceridemia
Authors: Modi Ankur , Scholz Beth , Wenkert David
Published: May 2020

Tocilizumab (TCZ) is a monoclonal antibody against the IL-6receptor used in the treatment of rheumatoid arthritis (RA). Hypertriglyceridemia is a rare side effect of TCZ, occurring in<1% of cases (1).

A 37 year-old woman presented with abdominal pain, nausea and diarrhea. Her past medical history included RA and dyslipidemia; she had no history of diabetes, hypothyroidism, renal disease, alcoholism or recent medication changes. Following failure of other immunosuppressant agents, IV TCZ was initiated. After two and a half years, TCZ formulation was changed to subcutaneous injections for convenience about 6 weeks prior to presentation. Family history included mother with dyslipidemia. Her vital signs were normal on admission with labs remarkable for lipase of 332 and triglycerides (TG) of 5680. Her TG 2months prior to initiating subcutaneous tocilizumab therapy was 1373. CT abdomen demonstrated findings of acute pancreatitis (AP). She was subsequently admitted to the ICU and started on an insulin drip, fibrate, statin and fish oil along with supportive care. TCZ was held. Because her TGs remained severely elevated, she was transferred to our facility for plasmapheresis with subsequent improvement of the same to 768 after two treatments.

TCZ was considered the probable etiology of her hypertriglyceridemia with subsequent AP after ruling out other secondary causes. Hereditary hypertriglyceridemia, given her family history, likely contributed to her chronically elevated TG’s.

TCZ has been reported to increase TG levels mainly through an increase in VLDL-TG content. TCZ was found to reduce hepatic LDLr expression thus reducing hepatic clearance of TGs and LPL mediated lipolysis of TG-rich lipoproteins (2). Despite the association of TCZ with increased lipid levels, it has a favorable impact on lipid metabolism via improved functionality of HDL-C and no impact in the atherogenic index; patients also experience a favorable response to statin treatment (3). In observational studies, TCZ shows a favorable effect on myocardial infarction compared to other biologic agents for RA, attributed partly to a decrease in lipoprotein(a) levels. Nonetheless, it should be used in caution in those with high cardiovascular risk, especially dyslipidemia (4).

1. Flaig T, Douros A. Tocilizumab-induced pancreatitis:case report and review of data from the FDA Adverse Event Reporting System. Journal of Clinical Pharmacy and Therapeutics 2016,

41:718-721.

2. Strang A, Bisoendial R. Atherosclerosis 229(2013):174-181.

3. Garcıa-Gomez C, Martın-Martınez M. Lipoprotein(a) concentrations in rheumatoid arthritis on biologic therapy:Results from the CARdiovascular inrheuMAtology study project. Journal of Clinical Lipidology (2017) 11:749-756.

4. CastagnéB, Viprey M. Cardiovascular safety of tocilizumab: A systematic review and network meta-analysis. PLoS ONE 14(8):e0220178.
SUN-388 Role of QUS and Functional Tests in Evaluating Fracture Risk Based on Frax Tool
Authors: Gama Eduardo Medeiros Ferreira , de Pinho Leandro Kasuki Jomori , Madeira Miguel , Duarte Carlos , Pessoa Girlene Canhete , Moraes Aline Barbosa , Amaral Maria Caroline Alves Coelho , Neto Francisco Paula Paranhos , de Farias Maria Lucia Fleiuss
Published: May 2020

Background: Osteoporosis is common among elderly people, and identifying those at high risk for fracture is very important.

Aim: To evaluate whether the use of quantitative calcaneal ultrasound (QUS), the Sitting–rising test (SRT) and handgrip test (HT) are additional tools for tracking fragility fracture risk when compared to FRAX and NOGG.

Methods: During the national campaign against osteoporosis, held in 2018 in Rio de Janeiro, participants were randomly selected to perform QUS, SRT and HT, besides categorization of the risk of major and hip fractures by FRAX and NOGG. The following adequacy values ​​were used: QUS T-score> -1.05 (adequate) or ≤ -1.05 (inadequate);

Sitting – rising test (SRT) (composite score): age-reference values at quartiles 3 and 4 (adequate); quartiles 1 and 2 (inadequate); best result 3 attempts of the dominant arm handgrip test, according to age and gender: percentile ≥50 (adequate) and <50 (inadequate); FRAX tool: suggests high risk for major osteoporotic fractures if > 20% and for hip fractures when > 3%; NOGG (complement to FRAX): patient′s risk for major and for hip fractures considered as low (green zone), medium (yellow zone) or high (red zone). Qui square test was used for associations.

Results: We included 162 individuals: 118 females, mean age 66.8 years and 44 males, mean age 71.8 years. High risk of hip fractures by FRAX was observed in 51% of those patients with a QUS T-score ≤-1.05 while it was observed in 28% of those with a QUS T-score> -1.05 (p=0.005). An inadequate QUS T-score was also associated with a higher risk of hip fracture by NOGG (p=0.007). An inadequate SRT and HT were not associated with a high fracture risk.

Conclusions: As densitometry, a method established in clinical practice for the diagnosis of osteoporosis, has limitations in its use, other tools are necessary for tracking the risk of fragility fractures in these events. Quantitative calcaneal ultrasound was a good predictor of hip fracture risk, while SRT and HT were not capable of evaluate for fracture risk stratification in our study, reinforcing the need for QUS for screening in large populations. Having strength and functional ability did not eliminate the need for investigation.
SAT-443 Impact of Fasting on Plasma Thyrotropin in Hypothyroid Patients Taking Levothyroxine During Ramadan (IFT-R Study)
Authors: El-Kaissi Samer , AbdelWareth Laila , Dajani Ruba , St John Terrence Lee , Santarina Sherry Ann , Makia Fiona , AlTakruri Malak , Kaskas AbedElRahman , Ahmed Yahya
Published: May 2020

Background and Aim: We previously showed in a retrospective analysis that the plasma TSH rises significantly post-Ramadan in levothyroxine-treated hypothyroid patients, possibly as a result of changes in the eating habit during the non-fasting period from dusk until dawn. The aim of this study is to determine the best time for taking levothyroxine during Ramadan in order to minimize changes in thyroid function tests.

Methods: in a randomized prospective design, hypothyroid patients taking levothyroxine for greater than 6-months were randomized to take levothyroxine at one of the following 3 times during Ramadan: (group 1) at dusk after a prolonged fast and 30-minutes before the Iftar meal, (group 2) ≥ 3-hours after the Iftar meal, or (group 3) at dawn 30-minutes before Suhur meal. Patients were instructed to allow a minimum of 3-hours between the last meal and levothyroxine and to refrain from eating and drinking for at least 30-minutes after taking levothyroxine. Thyroid function tests were performed within 3-months before Ramadan and within 6-weeks post Ramadan. To estimate intent-to-treat effects, we examined pre- and post-Ramadan thyroid function tests in relation to the assigned levothyroxine administration times.

Results: 147 patients were randomized into the study and the respective number of patients in groups 1, 2 and 3 were 50, 46 and 51. The mean age of participants was 43.5±12.4 years [range 21.0-86.0] and 78% were females with no statistical differences in the mean age or gender distribution between the 3 groups. The respective pre-Ramadan mean TSH values for the 3 groups were 2.49 mIU/L, 2.16 mIU/L and 3.37 mIU/L with no significant differences at baseline. Post-Ramadan mean TSH values were 2.47 mIU/L, 4.26 mIU/L and 3.85 mIU/L for groups 1, 2 and 3 respectively. The pre- and post-Ramadan mean TSH differences were significant only for group 2, who took levothyroxine 3-hours post-Iftar (P-value 0.041). There were no significant differences in the free-T4 levels across the 3-groups before and after Ramadan. In a subset of 85 patients, the preferred times for levothyroxine administration during Ramadan were 44.7% before Iftar, 50.6% post-Iftar and only 4.7% were in favor of taking the medication before Suhur meal.

Conclusions: Levothyroxine-treated hypothyroid patients who took levothyroxine 3-hours after the main Iftar meal showed a significant increase in plasma TSH post-Ramadan, possibly reflecting a reduced time period between levothyroxine administration and the previous meal. There was no significant change in the mean plasma TSH for patients taking levothyroxine at dusk before Iftar or at dawn before Suhur. The least patient-preferred time for taking levothyroxine was at dawn before Suhur possibly due to time constraints before the start of fasting.
SAT-630 Nutritional Influences on One Carbon Metabolism Exacerbate Diabetic Cardiomyopathy and Nephropathy
Authors: Al-Humadi Ahmed W , Strilakou Athina , Al-Humadi Hussam W , Al-Saigh Rafal , Liapi Charis
Published: May 2020

Choline (Ch) exerts a key role as methyl donor in the one carbon pathway and is an essential nutrient for the optimal development and function of a number of biological systems including the cardiovascular and urinary system. Ch-deprivation has been associated with heart function impairment, insulin resistance, abnormal fat metabolism and acute kidney injury. Diabetes mellitus is a common metabolic disorder with increased prevalence in aging and diabetic patients are of higher risk to develop heart and kidney failure. This study aims to investigate the impact of dietary Ch-deprivation on cardiac and renal function in a streptozotocin (STZ) experimentally induced diabetic setting. Twenty-four male adult Wistar rats, were randomly separated into four groups: control, choline deficient through choline deficient diet (CD), STZ induced diabetic (DM) and diabetic-choline deficient (DM+CD) group. After 5 weeks of dietary intervention, echocardiographic measurements, myocardium and kidney histological examination along with Vascular Endothelial Growth Factor-A (VEGF-A165) and Kidney Injury Molecule-1 (KIM-1) immunohistochemistry expression were performed. DM+CD rats demonstrated an exacerbation of myocardial inflammation and fibrosis accompanied by preserved ejection fraction but with an increased left ventricular (LV) wall tension index and velocity and a decreased LV posterior wall thickness compared to DM group. VEGF-A165 expression both in heart and kidneys was abruptly upregulated in the CD rats with a downward trend under the diabetes mellitus entity reaching significant downregulation in the renal tissue. KIM-1 expression was significantly increased under the insult of both choline deficiency and diabetes mellitus depicting a possible synergistic, though detrimental, effect compared to each condition alone.

In conclusion, five weeks of dietary choline deprivation aggravates the inflammation and fibrosis in the heart and kidneys of diabetic rats leading to organ dysfunction. The structural impairment of the choline deprived diabetic heart with evidence of stiffness and dilation of the left ventricular cavity with preserved systolic function indicates the emergence of a new distinct phenotype of cardiomyopathy that combines features of the restrictive and dilated type at the same time. Moreover, in this setting the kidney injury gets worse implying that diabetic nephropathy might establish earlier and accelerate more quickly in choline deficiency conditions.
SAT-623 Glucose Intolerance Modifies the Association Between Insulin-Like Growth Factor-1 and All-Cause Mortality
Authors: Visaria Aayush , Dharamdasani Tina
Published: May 2020

Background: Despite an increase in literature on insulin-like growth factor-1 (IGF-1) and its impact on insulin sensitivity, there remains controversy over its association with all-cause mortality. Insulin interacts with IGF-1 and its binding proteins, forming a growth hormone/IGF-1/insulin axis that may be impaired in Type II diabetes and/or prediabetes. We hypothesized that the association between insulin and IGF-1 with all-cause mortality differs in those with glucose intolerance (GI) in a nationally representative U.S. population with long-term follow-up. Methods: A total of 5,283 non-pregnant adults >20 years from the National Health and Nutrition Examination Survey (NHANES)-III (1988-1994) were linked to the National Death Index through 2015. Glucose intolerance was classified as per fasting blood sugar (≥100 mg/dl), hemoglobin A1c (≥5.7%), medication use, or self-reported diagnosis. IGF-1 was categorized into sex-specific quartiles. To analyze the joint impact of insulin and IGF-1, we also categorized participants into four groups: Group I) IGF-1 <230 ng/mL & insulin ≥11 uIU/mL, II) IGF-1 <230 & insulin <11, III) IGF-1 ≥230 & insulin ≥11, and IV) IGF-1 ≥230 & insulin <11. Our primary outcome was all-cause mortality. We used survey design-adjusted Cox regression to estimate the risk of all-cause mortality, adjusting for confounders. Results: Among the 5,283 subjects, 2,214 (42%) had GI. Participants had a mean follow-up of 22.1 years, during which 1,835 (34%) of them died. Those with GI in the highest quartile of IGF-1 had an unadjusted 64% lower risk of all-cause mortality compared to the lowest quartile (GI = unadjusted OR [95% CI]: 0.37 [0.24,0.55]). This association, although protective, was significantly less protective than those with normal glucose tolerance (NGT) (unadjusted OR: 0.16 [0.12,0.23]). After adjusting for confounders, these associations became insignificant (GI = aOR: 1.02 [0.73,1.42], NGT = aOR: 1.04 [0.74,1.46]). When estimating risk of mortality among joint groups of insulin and IGF-1 levels, those in Group I with NGT had 20% increased adjusted odds of mortality (1.30 [1.01,1.71]), while in GI subjects, there was an insignificant increased odds of mortality (1.17 [0.84, 1.62]). Neither subgroup in Group 2 had significant adjusted odds of mortality relative to Group 4. Group 3 subjects with GI had an adjusted, insignificant 24% increased odds of mortality (1.24 [0.91, 1.70]) compared to 70% increased odds in NGT subjects (1.69 [1.18, 2.42]). Conclusion: The differences in odds of all-cause mortality across IGF-1 quartiles in glucose tolerant vs. intolerant individuals suggests that IGF-1 may play less of a protective role in Type II diabetes and prediabetes. Among those with normal glucose, higher insulin levels, regardless of IGF-1 levels, was associated with all-cause mortality. This association did not hold in those with glucose intolerance.
SAT-194 Pheochromocytoma During Pregnancy: A Ticking Time Bomb
Authors: Sarmiento-Ramon Juan Camilo , Sosa-Pagan Max , Dendy Jared
Published: May 2020

Background: A pheochromocytoma diagnosed during pregnancy is an extremely rare condition with an incidence of 0.002% of all pregnancies. If untreated, consequences are devastating including a maternal and fetal mortality as high as 50%. There is no consensus in the literature regarding the management of this condition during pregnancy.

Clinical Case: A 25-year-old woman G4P1021 presented at 15 weeks of gestation with shortness of breath, palpitations and chest pain. Vitals revealed hypertension and tachycardia. A CT angiogram of the chest was obtained which ruled out a pulmonary embolism but detected a 5.5-cm left adrenal mass. Biochemical work up revealed elevated plasma and urine normetanephrines. A dexamethasone suppression test was normal. A plasma aldosterone to renin ratio was normal. An MRI of the abdomen confirmed the presence of a large heterogeneous 6-cm left adrenal mass. A multi-disciplinary team discussion including an obstetrician, endocrinologist, endocrine surgeon and anesthesiologist led to the decision to perform an adrenalectomy during the second trimester. Doxazosin was started at a dose of 2 mg daily, which was later titrated up to 2 mg BID with excellent blood pressure control. Metoprolol was added 4 days prior to surgery for heart rate control. A laparoscopic left adrenalectomy was performed at 19 weeks of gestation. Intra-operatively, the patient had a brief period of hypotension which resolved with IV fluids and a short course of vasopressors. Patient did not have any post-operative complications and is currently normotensive and with a normal heart rate without the use of any anti-hypertensive medications. Repeat plasma metanephrines and normetanephrines were within the reference range. Her latest obstetric ultrasound at 20 weeks of gestation revealed a live fetus without anatomical abnormalities. The fetus is within the normal weight and size percentiles.

Conclusion: A pheochromocytoma is a rare event during pregnancy and is associated with high maternal and fetal mortality rates. Timely diagnosis and proper treatment are of utmost importance to reduce mortality. The optimal time for surgical tumor removal has not been established but the second trimester appears to be safest period given the risk for spontaneous abortion during the first trimester and that the enlarged uterus diminishes tumor accessibility during the third trimester. Pre-operative medical management is crucial similar to non-pregnant patients. The treatment of these patients should include a dedicated team including an obstetrician, anesthesiologist, surgeon and endocrinologist.
SUN-491 A Diagnosis of Thyroid Cancer Reveals a Triple Threat
Authors: Dengler Samuel Lee , Reid Lisa , Klump William , Shersher David , Squillante Christian , Ferber Andre , Morgan Farah Hena
Published: May 2020

Introduction: The risk of secondary malignancies is increased in patients with papillary thyroid cancer (PTC). It is not completely clear if this risk is due to radioactive iodine treatment or due to other causes. We present a case of a patient diagnosed with papillary thyroid cancer (PTC) found to have lung cancer and small lymphocytic lymphoma which appear to be unrelated to radioactive iodine treatment.

Case Presentation: A 72 yo woman with a history of Graves’ disease, atrial fibrillation, and hyperparathyroidism initially presented to care for weight loss. She was found to have hyperthyroidism and was treated with methimazole. Thyroid ultrasound revealed multiple nodules including a 17mm right lower pole nodule with irregular borders for which she underwent FNA. Pathology demonstrated atypical-cells of undetermined significance (AUS), but thyroseq revealed a BRAF V600E mutation. She underwent total thyroidectomy with pathology showing multifocal thyroid cancer, 12mm and 0.8mm with 3/11 involved lymph nodes and right parathyroid adenoma. Given a questionable lower left lung nodule on preop CXR, she underwent CT chest which revealed a 2cm lung nodule. She had video assisted thoracoscopic (VATS) left lower lobe wedge resection with completion left lower lobectomy for a 3 cm lung adenocarcinoma with negative margins and 33 negative lymph nodes. She was subsequently treated with RAI after recovery from VATS procedure. Pretreatment thyroglobulin was 0.8 ng/ml with negative thyroglobulin antibodies. One month after her RAI treatment, ultrasound of the neck revealed suspicious bilateral level IV lymph nodes which increased in size during short term follow up. Serum thyroglobulin was 0.3ng/ml with negative antibodies and TSH 0.29 mIU/L. Biopsy of right level IV lymph node was positive for PTC with thyroglobulin washout >5000 while left level IV lymph node was negative for PTC and Tg washout was 0.1. She subsequently underwent right-sided modified radical neck dissection, with lymph nodes revealing PTC also involved by small lymphocytic lymphoma. She had repeat RAI ablation for thyroid cancer and is being actively monitored for her small lymphocytic lymphoma and lung adenocarcinoma.

Conclusion: We present a patient with no known history of malignancy who presented with 3 de novo primary malignancies. This case may demonstrate an increased risk of malignancy in patients with thyroid cancer not necessarily related to radioactive iodine treatment.
MON-909 Diabetic Ketoacidosis Following Treatment of Endogenous Hyperinsulinism
Authors: Murari Keerti , De Aguiar Renata Da Silva Belfort
Published: May 2020

Background: There has been only one case of Diabetic Ketoacidosis (DKA) reported following treatment of endogenous hyperinsulinism in a 16 month old.[1] This has not yet been described in adults.

Clinical Case: An 85 Y/O M with a PMH of metastatic gastric adenocarcinoma complicated by gastric outlet obstruction requiring TPN was admitted for symptomatic hypoglycemia. On the day of admission, his wife noted that he appeared confused and checked his capillary blood glucose, which was 35, prompting her to call EMS who gave him IV dextrose 50% (D50).

In the ED, he was placed on continuous dextrose 10% (D10) due to persistent hypoglycemia. To investigate the cause of hypoglycemia, D10 was stopped and a fast test was initiated. The patient developed symptomatic hypoglycemia 9 hours after stopping the D10. Laboratory results showed: plasma glucose 43 mg/dL, c-peptide 3.1 nmol/L, pro-insulin 18.7 pmol/L, insulin 10.7 uU/mL, beta-hydroxybutyrate (BHOB) 0.08 mmol/L. Insulin antibody and screen for oral hypoglycemic drugs were negative. Glucagon administration raised his blood glucose from 43 mg/dL to 50 mg/dL, 84 mg/dL, and 106 mg/dL after 10, 20, and 30 minutes, respectively. A diagnosis of endogeneous hyperinsulinism was made and the patient was started on Diazoxide 50 mg TID which was increased to 150 mg TID 2 days later. On day 3, Prednisone 20 mg daily was started due to inability to come off the D10 drip completely. On day 4 he was taken off D10. Due to plasma glucose >150 mg/dL, prednisone dose was reduced to 10 mg and then 5 mg on day 5 and 6, respectively. On day 8, he was found to be in DKA with a plasma glucose of 250 mg/dL, metabolic acidosis with an anion gap of 20, HCO3 of 15 mg/dL, undetectable insulin levels and BHOB of 5.49 mmol/L. Prednisone and Diazoxide were discontinued and he was started on an intravenous insulin infusion. Within 24 hours he became persistently hypoglycemic requiring D50 and prednisone was restarted. DKA developed once again and the patient was subsequently made comfort measures only. Further investigation of his endogenous hyperinsulinism was not pursued. The patient was transferred to inpatient hospice, where he passed away several days later.

Conclusion: This is the first reported case of an adult patient with documented endogenous hyperinsulinism developing DKA following treatment with diazoxide and prednisone. Reference: (1) Mangla et al. J Ped End Met. 2018; 31(8): 943-945.