bluuebunny/crossref_metadata_2025_split huggingface dataset:
SUN-906 To Function or Not to Function: A Rare Case of Metachronous Hormone Syndrome
Authors: Amine Adele , Ghanta Neelima , Reynolds Raymond 
Published: May 2020

Abstract
This is a 51-year-old female with a history of metastatic neuroendocrine tumor of the pancreas diagnosed four years ago who was admitted to the to the hospital for hypoglycemia. She initially had come to the hospital for alternative treatment of her disease using PRRT (peptide receptor radionuclide therapy). Prior to receiving treatment the patient had been asymptomatic. After receiving her first dose of PRRT the patient developed acute encephalopathy. Upon evaluation she was noted to be oriented only to person, lethargic and confused. Finger stick blood glucose at the time of her symptoms had read 17. The patient was immediately placed on D10 with improvement of her symptoms and increase of glucose to the 70s. An attempt was made to wean the patient off of dextrose however the patient continued to experience persistent hypoglycemia. Thus investigation of an insulin-secreting tumor was done. C-peptide was 3.98 ng/mL (0.81 - 5.30 ng/mL), insulin level was 26.7 uU/mL (3.0-16 uU/mL) and proinsulin level was 556 pmol/L (&lt;22 pmol/L), while her serum glucose was below 45. Given her biochemical markers as well as improvement in glucose when treated the patient was started on Diazoxide for presumed insulinoma. Due to intolerance to the medication she was switched to Octreotide with success.
Here we present an unusual case of Metachronous Hormone Syndrome (MHS) in a patient who at presentation of her diagnosis was already found to have metastatic pancreatic neuroendocrine tumor. Typically NET present in the 4th to 6th decades of life and have the potential to secrete peptide hormones. Occasionally patients with tumors that appear to be nonfunctional develop symptoms of hormone secretion later in their disease such as our patient. Furthermore it is uncommon for a patient to present with metastatic NET; such was not the case for our patient. Metachronous hormone syndrome is not fully understood but may be an indication of tumor progression. In addition its mechanism of action is unknown and its been theorized to be induced by anti-tumor treatments. Perhaps this case may allow us to better understand MHS in a broader context, as this patient was found to have progression of her disease when she initially was diagnosed 4 years ago and recently presented with symptoms consistent with an insulinoma. Lastly her case may further guide us in studying various treatments for NET and their role in triggering MHS.
References 1. De Mestier, Louis et al. Metachronous hormone syndromes in Patients With Pancreatic Neuroendocrine Tumors: A Case Series Study. Annals of Internal Medicine. 2015; 162 (10): 682-689. 2. Mathur, A, Gorden, P and Libutti SK. Insulinoma. The Surgical Clinics of North America. 2009-10-01, Volume 89, Issue 5, Pages 1105- 1121. 3. Igarashi, H, Hiijoka, M, Lee, L and Ito, T. Biotherapy of pancreatic neuroendocrine tumors using somatostatin analogs. Journal of Hepatobilliary Pancreatic Sciences. 2015, Volume 22, Issue 8.
SUN-312 Strikingly Low Prevalence of Pituitary Incidentalomas in Our Hospital
Authors: Sosa Natalia , Rivero Florencia , Tripodi Diego , Negrotto Matias , Lima Ramiro , Pineyro Maria Mercedes 
Published: May 2020

Abstract
Introduction: Pituitary incidentalomas (PIs) have been reported in 10.6% of autopsies, 4-20% in computed tomography scans (CT) and 10-38% in magnetic resonance imaging (MRI), most of them microincidentalomas(&lt;1cm). They may be have autonomous hormonal activity or impair normal gland function. The frequency of PIs in Uruguay is unknown. We aimed to investigate the prevalence of pituitary incidentalomas in our Hospital. Methods: We retrospectively identified all patients who underwent brain CT and MRI at our hospital over a 1-year period for disorders other than known or suspected pituitary disease. The period covered was from January 1 to December 31, 2017. We reviewed all scans; anamnesis and biochemical evaluation was performed on patients who presented PIs. Results: During this period 3894 patients underwent imaging studies. MRI was performed in 1146 patients, and CT in 2748 of them. Mean age was 53,1 ± 19 years, with similar gender distribution (50.6% women). Most imaging studies where ordered in the emergency department (43%), followed by the outpatient clinics (29%) and inpatient wards (28%). Most common reasons that led to request the image were trauma (20.4%), headaches (11.3%) and stroke (10.9%). We detected two PIs, which accounts for a prevalence of 5 cases per 10,000 individuals per year (0.05%). Both where detected by CT, with a MRI done later to further evaluate them. Final diagnosis was of a vascular aneurysm and a sellar meningioma. Work-up showed a secondary hypothyroidism in the patient with the sellar meningioma. No cases of pituitary adenomas were found. Discussion: We observed a strikingly lower prevalence of PIs than that reported in the literature. In addition, no PIs where found in MRI. Moreover, no pituitary adenoma was discovered. The reasons for these findings are unknown. In our study scans were not focused to the pituitary fossa so small lesions may have been missed. However, Esteves et al(1) reported a prevalence of PIs 5.8% in 1232 patients who had head MRI/CT, not pituitary MRI. In addition, the majority were pituitary adenomas, almost 40% of them microadenomas. Slices of 2-mm thickness were obtained in the scans, similar to imaging techniques used in other studies. Most reports have longer study duration (3-5 years).Our hospital is a teaching hospital where fellows evaluate scans initially, which are then reevaluated by neuroradiologists. This may account for the prevalence found, as sensitivity may be lower when professionals in training evaluate scans. In addition, frequency of pituitary hipointensity areas may decrease as the number of reviewers increase. Furthermore, this low prevalence could be related to difference in population characteristics.Conclusions: We found a very low prevalence of PIs in our hospital. More studies are warranted to further investigate frequency of PIs in our country. (1)Esteves et al. Pituitary. 2015;18(6):777-81.
MON-498 Thyroseq V3 GC for Bethesda III and IV: An Institutional Experience
Authors: Desai Dimpi , Lepe Marcos , Kim Caroline S , Kobaly Kristen , Baloch Zubair Wahld , Mandel Susan J 
Published: May 2020

Abstract
Background:
Molecular testing of thyroid nodules classified as indeterminate on fine-needle aspiration (FNA) is used for patient management. ThyroSeq® v3 genomic classifier is a commercially available test that examines a wide spectrum of genomic alterations in a thyroid FNA sample based on algorithmic analysis and reports test results as either negative (including currently negative) or positive. This study reviews our institutional experience with Thyroseq® V3 to distinguish between benign disease versus cancer in thyroid nodules diagnosed as Bethesda III or IV on cytology.
Methods:
Thyroid nodules with Bethesda III or IV cytology diagnoses and available Thyroseq® V3 results from 12/17 to 8/19 were retrieved from the pathology database. Cytopathology diagnoses were correlated with molecular testing and histopathology.
Results:
416 cases (Bethesda III n=252, Bethesda IV n=164) were retrieved: 295 (71%) were reported as Thyroseq® V3 negative and 121 (29%) as positive. The 82.1% (207/252) benign call rate (BCR) of Thyroseq® v3 for Bethesda III was significantly higher (p&lt;0.001) than that for Bethesda IV, BCR 54% (88 /164). Histopathologic follow-up was available for 128 cases (96 ThyroSeq® v3 positive, 32 ThyroSeq® v3 negative): 57 benign and 71 malignant (including NIFTP). For Bethesda III and IV diagnoses respectively, the test demonstrated 91.7 % (95% Cl 73%-99%) and 91.5% (95% Cl 80%-98%) sensitivity, 94% (95% Cl 90%-97%) and 82.4% (95% Cl 74%-89%) specificity, 99% (95% Cl 96%-99%) and 95% (95% Cl 89%-98%) negative predictive value and 63% (95% Cl 50%-74%) and 70.5% (95% Cl 61%-79%) positive predictive value, given malignancy rates 10% Bethesda III; 32% Bethesda IV. 45 unique combinations of genetic alterations were detected in the 96 operated ThyroSeq® v3 positive cases—34 combinations (76%) were present in &lt;2 cases and only 3 combinations occurred 7 or more cases. Forty-six (48%) nodules had RAS mutations, either combined with other mutations 31% (23/30, 77% malignant) or alone, 17% (10/16, 63% malignant), followed by
THADA/IGF2BP3 gene fusion changes,11.5% (10 /11 malignant). Three cases with BRAF mutations (1 V600E, 1 K601E, 1 K601N) were malignant. Copy numbers alterations alone were present in 10 (5/ 10 malignant) and the gene expression profile alone was positive in 5 cases (all malignant). Mutations that were associated with benign pathology were PTEN, DICER1, E1F1AX and TP53. There were 6 false negative cases, 5 low risk cancers by American Thyroid Association criteria and 1 NIFTP.
Conclusion:
The high BCR of Thyroseq® v3 for Bethesda III category avoids surgery for majority of patients. A more comprehensive mutational and fusion panel reveals the complexity of the genetic signature of indeterminate nodules. Future larger and likely multicenter studies will be required to define the associated cancer risk and potential prognosis associated with adjunct molecular testing.
SUN-166 Primary Adrenal Insufficiency Caused by Underlying Tuberculosis
Authors: Jamal Umara Zahir 
Published: May 2020

Abstract
Introduction
Primary adrenal insufficiency (AI) is a rare endocrine disorder affecting 1 in 100,000 people. Primary AI is a gradual destruction of the adrenal cortex. Etiology includes autoimmune, tuberculosis, histoplasmosis, blastomycosis, adrenal metastases, primary adrenal tumors, and opportunistic infections of HIV. Since aggressive treatment of TB, the incidence of TB adrenalitis has significantly declined, now accounting for 20% of reported cases where as autoimmune causes of AI account for 70%. Most common symptoms are non-specific, and diagnosis is often delayed, with patient initially presenting with a life-threatening adrenal crisis.
Case
Patient is an incarcerated 65 y/o African American male with PMHx of hypothyroidism who was admitted to the hospital for AMS after being found unresponsive in his prison cell. On admission, patient was febrile, hypotensive and tachycardic. He looked disheveled, confused, and lethargic. Other exam findings were negative.
Lab results revealed WBC 11.7/μL, serum sodium 116 mmol/L, serum potassium 5.2 mmol/L, serum glucose 68 mg/dL, serum osmolality 237mOsm/kg, TSH 26.3mIU/L, and random cortisol 1.6ug/dL. ACTH stimulation test revealed pre-challenge cortisol levels 5.1ug/dL, 30-minute 4.9ug/dL and 60-minute 4.5ug/dL. ACTH 1271 pg/mL (normal range 7.2-63.3pg/mL). A normal response is a stimulated cortisol level &gt; 18ug/dl. Chest x-ray revealed left lower lobe pneumonia.
Clinical signs/symptoms and labs were consistent with primary AI. Adrenal crisis was most likely precipitated by underlying pneumonia. Workup was negative for 21-Hydrolase Antibodies, HIV, CMV, and histoplasmosis. However, QuantiFERON-TB Gold Test was positive. Abdominal CT revealed bilateral enlarged non-enhancing adrenal nodules with coarse calcifications. Biopsy of right adrenal gland revealed necrotizing caseating granulomatous inflammation. Biopsy was negative for isolated aerobic, anerobic, fungal organisms, AFB, and mycobacterium PCR.
Due to current findings and high suspicion of TB adrenalitis, patient is currently being treated as culture-negative tuberculosis along with PO hydrocortisone for underlying AI.
Discussion
Adrenal tuberculosis is a rare cause of primary adrenal insufficiency in developed countries. There should be high suspicion for AI when a patient presents with hypotension, hyponatremia, hyperkalemia and/or hypoglycemia. In this case, although patient did not have a positive AFB culture, he did have a positive QuantiFERON-TB Gold Test along with consistent findings on CT and biopsy. Thus, case was concluded to have high suspicion of primary AI secondary to underlying untreated tuberculosis. Prompt treatment with antituberculosis medication, appropriate steroid therapy, along with monitoring of adrenal function, underlying adrenal insufficiency may be reversible if detected in early stages and decrease mortality.
MON-117 Reducing Unnecessary Repeat Vitamin D Testing at a Large Ambulatory Hospital: A Quality Improvement Initiative
Authors: Koshkina Olexandra , Boggild Miranda , Tai Felicia , Mukerji Geetha 
Published: May 2020

Abstract
Background:
With the increasing interest in the importance and potential benefits of vitamin D, there has been a significant rise in unnecessary vitamin D testing.
The aim of the project was to reduce unnecessary repeat vitamin D testing at Women’s College Hospital by 50% by May 30th 2020.
Methods:
The Model for Improvement framework was used in the design of the quality improvement project to reduce unnecessary repeat vitamin D testing. Problem characterization was conducted to design the intervention to address root causes and iterative Plan-do-Study-Act cycles were used to develop an intervention that incorporated a best practice advisory (BPA). The primary outcome measure was unnecessary vitamin D testing. Unnecessary repeat testing was defined as: repeat 25-hydroxyvitamin D testing within 3 months or repeat 25-hydroxyvitamin D testing after a normal result (&gt;75 mmol/L) in the preceding 12 months.
Secondary outcomes which included BPAs generated, as well as the number of BPAs that resulted in no test being ordered were tracked. Paper-based orders were also tracked as a balancing measure.
Results:
It was identified that 12.7% of vitamin D testing (n= 289/2276) between July 2017 and July 2018 was related to unnecessary repeat testing. Following our cause and effect analysis and problem characterization, it was noted that providers ordered repeat vitamin D testing due to being unaware of prior normal results, as well as due to a knowledge gap of current testing recommendations. If the 25-hydroxyvitamin D order was identified as unnecessary at the time of order entry, a BPA was generated at the point of care. The BPA was implemented on February 4th, 2019. As of August 31st, 2019 based on the analysis of the number of BPAs generated and the number of tests not ordered as a result, there has been a 26% reduction in the number of inappropriate repeat vitamin D orders.
Conclusions:
Based on the preliminary data, a best practice advisory alert for vitamin D testing can be an appropriate QI intervention to reduce unnecessary vitamin D testing. Ongoing data analysis will be conducted to assess the long-term impact and sustainability of this intervention. Next steps include consideration of implementation of force function to reduce inappropriate repeat vitamin D testing.
SAT-503 Levothyroxine Absorption Testing in Three Patients with Severe Hypothyroidism on Adequate Replacement
Authors: Martinez Eduardo Andres Lopez , Carlson Scott , Force Bahar Kapoor , Kanji Aleem , Jiang Bryan , Ram Nalini 
Published: May 2020

Abstract
Background: Levothyroxine (L-T4) absorption is a concern in patients who report appropriate self-administration but remain clinically and biochemically hypothyroid. However, there are no established guidelines for L-T4 absorption testing.
Clinical Cases: Two women (A and B) with a history of Graves’ disease and radioactive iodine ablation (RAI) on weight-based L-T4 replacement presented to the hospital with severe fatigue and bilateral leg swelling. A third woman (C) with a history of papillary thyroid carcinoma, total thyroidectomy and RAI, on suppressive doses of L-T4 presented to the clinic with fatigue, constipation and weight gain. All patients reported compliance with taking L-T4 with appropriate technique. They had no known medical problems contributing to a malabsorptive state, and were not taking any medications known to interfere with L-T4 absorption.
Initial testing of thyroid function revealed TSH (0.57-3.5 μIU/mL)/Free T4 (0.61-1.18 ng/dL) levels of 10.12/0.249, 45.95/&lt;0.2 and 142/&lt;0.2 in patients A, B and C respectively. Patients A and B tested negative for Helicobacter pylori infection, celiac disease and lactose intolerance. Patient C had been successfully treated for H. pylori infection in the past. Celiac testing was negative, but the patient tested positive for anti-parietal cell antibodies and vitamin B12 deficiency. She was referred to Hematology & GI specialists. None of the patients had clinical evidence of heart failure and had normal echocardiograms.
In order to evaluate for poor absorption, all patients underwent L-T4 absorption testing. Based on published data, baseline TSH and Free T4 levels were obtained followed by administration of 1000 mcg of L-T4. Next, free T4 levels were obtained at 2 hours for all patients and at 4, 8 and 24 hours for patient A & B. Patients A and B underwent testing in the inpatient setting, while Patient C was tested in the outpatient clinic.
In all cases, a &gt; 50% rise in free T4 levels was observed at 2 hours, suggesting non-adherence or “pseudo-malabsorption”. Patients were counseled extensively regarding proper technique and compliance with L-T4. Patients A and B demonstrated rapid clinical improvement in the hospital, and Patient C reported to her next clinic visit with clinical and biochemical improvement.
Conclusions: Though guidelines have not been established for L-T4 absorption testing, case reports exist exhibiting the safety and efficacy of L-T4 absorption challenge with a weekly weight-based dose or 1000 mcg of LT4. Our case series show the success of the latter with meaningful results in as little as 2 hours. Case C demonstrates that this test can be done safely and cost-effectively as an outpatient. Standardization of L-T4 absorption test will be of great utility in the management of this common problem encountered by endocrinologists.
SAT-470 When The Heart Can’t Clap To The Thyroid’s Beat
Authors: Thakkar Aditi , Trejo-Parades Maria Camila , Madgula Anantha Sriharsha , Stevenson Margaret 
Published: May 2020

Abstract
Hyperthyroidism is associated with multiple cardiac pathologies including dilated cardiomyopathy, isolated right ventricular heart failure, and atrial fibrillation (AF). Long standing untreated hyperthyroidism in conjunction with AF can cause severe dilated cardiomyopathy with reduced ejection fraction that is completely reversible with treatment. We present the case of a previously healthy male who presented with florid congestive heart failure (CHF) as an initial presentation for hyperthyroidism. A 37-year-old male presented to the emergency department with progressively worsening dyspnea on exertion and lower extremity edema for one month. His heart rate was noted to be 172 bpm and an EKG was done that showed AF. He was clinically noted to be in heart failure and was admitted for further management. He was started on metoprolol with good heart rate control and was started on furosemide for diuresis. A transthoracic echocardiogram was done and showed severe global hypokinesis with left ventricular ejection fraction reduced to 20% along with bi-atrial enlargement and dilated left ventricular cavity. Ischemic cardiomyopathy was ruled out with left heart catheterization. A TSH level was checked as a part of workup for non-ischemic cardiomyopathy and atrial fibrillation and was markedly reduced to &lt;0.01mIU/L with free T4 of 1.49ng/dL and free T3 of 6.7ng/dL. A diagnosis of hyperthyroid cardiomyopathy with concomitant tachycardia induced cardiomyopathy was made. Autoimmune workup was negative for anti-thyroid-peroxidase and anti-thyroid-stimulating antibodies. Ultrasound of his thyroid gland revealed multiple thyroid nodules concerning for toxic multinodular goiter. He was started on methimazole and discharged after volume optimization with diuresis to closely follow up with endocrinology and cardiology for further management. CHF can be the primary presentation in about 6% of patients with hyperthyroidism. T3 is the main thyroid hormone that binds to cardiomyocytes. It increases the expression of beta-adrenergic receptors on cardiomyocytes and subsequently increases heart rate and contractility. T3 can also cause atrial arrhythmias such as AF by decreasing the parasympathetic tone. Concomitant AF and hyperthyroidism can cause reduced ejection fraction due to tachycardia induced cardiomyopathy and dilated cardiomyopathy. Treatment mainly is with beta-blockers that slow down the heart as well decrease serum T3 levels by blocking 5-monodeiodinase which converts T4 to T3. Our patient was started on beta-blocker and methimazole with good reduction in heart rate and improvement of symptoms. Recovery of cardiac function will be assessed with longitudinal follow up. As hyperthyroidism is one of the few causes of CHF that is completely reversible, clinicians must maintain low degree of suspicion in patients with new onset heart failure especially when associated with AF.
OR13-06 Implementation of a High-Risk Fracture Program in an Integrated Healthcare Delivery System
Authors: Hamann Kendal L , Chandra Malini , Hui Rita L , Lee Catherine , Khan Mehreen M , Fulchino Lisa , Lo Joan Chia-Mei 
Published: May 2020

Abstract
BACKGROUND: Fracture events in older adults are important opportunities for secondary prevention. In response to national (HEDIS) quality metrics in 2008, our medical group implemented a fracture prevention program, identifying women age ≥65y who experienced a fracture and targeting them for osteoporosis screening or treatment within six months. In 2015, we added an outreach program for “high-risk secondary fracture prevention” targeting women age 60-85y and men age 70-85y for osteoporosis therapy within 6 months after a hip, pelvic, humerus, wrist or vertebral fracture. This study examines whether targeting “high-risk fracture” in women and men results in higher treatment rates following a non-vertebral major osteoporotic fracture.
METHODS: This retrospective study was conducted using data from women age 60-85y and men age 70-85y who experienced a fracture of the hip, humerus, and wrist in 2013-2014 (Cohort 1, the era of our HEDIS-only program) or 2015-2016 (Cohort 2, the era of our added “high-risk secondary fracture prevention” program). We excluded patients with primary bone disorders or metastatic cancer and those with osteoporosis treatment in the year prior to fracture. Osteoporosis drug therapy (oral/IV bisphosphonates, denosumab, raloxifene or teriparatide) initiated within six months after the fracture date was assessed. Differences between groups were compared using the chi-squared test, and multivariable logistic regression was used to examine predictors of treatment.
RESULTS: There were 5727 (Cohort 1) and 6469 (Cohort 2) adults identified with hip, humerus, or wrist fracture (high risk fracture). Wrist fracture was the most prevalent fracture in women and hip fracture the most prevalent in men. Osteoporosis treatment initiation within 6 months of the fracture date was achieved for 38% of women and 13% of men in Cohort 1 and 37% of women and 25% of men in Cohort 2. Among women age 60-64, treatment increased from 14% (Cohort 1) to 25% (Cohort 2). Overall, fracture in the later era (2015-2016) was associated with a slightly lower odds of post fracture treatment initiation (adjusted odds ratio OR 0.8, 95% confidence interval (CI) 0.7-0.9) in women 65-85y; however, a much higher odds of treatment was seen (OR 2.3, 95% CI 1.9-2.9) for men 70-85y. Older age, hip fracture, and past osteoporosis therapy were also associated with greater odds of treatment within 6 months.
CONCLUSION: Targeted high-risk fracture intervention resulted in a 2-fold increase in osteoporosis treatment after major non-vertebral osteoporotic fracture in men 70-85y and women 60-64y, the demographic subgroups not previously targeted by HEDIS-based intervention. However, treatment of fractures in women already targeted by HEDIS-based intervention did not increase. Future studies should address potential barriers to treatment and assess the impact of added high-risk fracture outreach on adherence to therapy.