bluuebunny/crossref_metadata_2025_split huggingface dataset:
MON-235 Mycobacterium Fortuitum Infection Mimicking Sellar Chondrosarcoma in a Non-Immunosuppressed Patient: An Unusual Cause of Hypopituitarism and Oculomotor Nerve Palsy
Authors: Mavromati Maria , Fitsiori Aikaterini , Janssens Jean-Paul , Jornayvaz Francois 
Published: May 2020

Abstract
A 32-year old male patient of central African origin presented with diplopia and left eyelid ptosis. He described a 2-month history of fatigue, weight loss (8 Kg), headaches, diffuse myalgia and night sweats. Clinical examination revealed cavernous sinus syndrome with left eyelid ptosis and weakness of eye adduction. Magnetic resonance imaging of the brain demonstrated a 36 mm mass centered on the left petroclival suture, infiltrating the sella and the pituitary gland, the ipsilateral orbital apex as well as the cavernous sinus bilaterally. The mass showed heterogenous enhancement after gadolinium injection, with elements of central necrosis and was associated with an extensive bone destruction. These radiologic features raised the hypothesis of chondrosarcoma. Chest computed tomography demonstrated multiple lung micro-nodules suspect of metastasis. Laboratory testing of the anterior pituitary function revealed low free-T4 (11 pmol/l, n = 12-22) with normal TSH (0.4 mUI/l, n=0.3-4.2), low total testosterone (1.5 ugr/l, n = 3.3-8.1) with normal LH and FSH and slight hyperprolactinemia (27 ugr/l, n = 4-15). IGF-1, 24-h urinary free cortisol, as well as morning serum cortisol and cortisol after 250 mcg ACTH stimulation test were normal. There was no evidence of diabetes insipidus. Levothyroxine was prescribed. Craniotomy was performed, for left optic nerve decompression and biopsy of the mass. Pathologic examination revealed granulomatous, giganto-cellular and necrotizing inflammation, but no evidence of malignancy. PCR for Mycobacterium tuberculosis complex was negative but Mycobacterium fortuitum was detected in sputum and also confirmed in cerebral biopsy latter. Other causes of granuloma were excluded (brucellosis, cat scratch disease, histoplasmosis, syphilis, coccidioidomycosis, tropical germs etc.). Different causes of immunosuppression (including HIV) were excluded. The patient was treated with amikacin, isoniazid and ciprofloxacin for several months and improved gradually. MRI performed one year later demonstrated significant decrease on the size of the sellar mass (more than 50% of its initial size). Central hypogonadism regressed spontaneously with decrease in tumor size, and normal testosterone levels were achieved at one-year follow-up (7 ugr/l, n = 3.3-8.1). Mycobacterium fortuitum infections of the sella turcica are poorly described in literature in non-immunosuppressed individuals. Although usually not pathogenic, histopathological examination, identification in the CNS lesion and the lungs and response to treatment are convincing evidence of a causal relationship. Differential diagnosis from malignant lesions is challenging and biopsy is necessary in order to establish the cause and offer adequate treatment.
SAT-497 Conversion of Hashimoto’s Thyroiditis to Grave’s Disease: A Case Report
Authors: Wahedi Tayba S , Douba Najah Younes 
Published: May 2020

Abstract
Introduction: Hashimoto’s thyroiditis and Grave’s disease are common causes for autoimmune thyroid disease. Conversion from Grave’s disease to hypothyroidism have been previously reported in literature. But development of Grave’s disease after a long standing hypothyroidism rarely occurs.Case report: a 22 -year-old Saudi pregnant female patient, was diagnosed with subclinical hypothyroidism with positive anti -thyroid peroxidase antibodies (Anti-TPO) in 2009. She was started on thyroxin and eventually became euthyroid with normal TSH levels till 2016. During subsequent follow-ups, patient was increasingly complaining of palpitations, weight loss and fine tremors. Thyroid function revealed increasingly suppressed TSH levels and over-replacement was suspected. Thyroxin dose was then gradually reduced and finally stopped for few months. Yet her symptoms persisted. Repeated thyroid function showed suppressed TSH level and elevated T4, T3 levels in keeping with overt hyperthyroidism. Thyroid scan further confirmed the diagnosis with diffuse thyroid uptake suggestive of Grave’s disease.Patient was started on medical treatment initially, then successfully treated with radioactive ablation.Conclusion: Although it rarely occurs, possibility of conversion from hypothyroidism to hyperthyroidism should always be kept in mind while treating hypothyroid patients with persistent clinical or biochemical evidence of hyperthyroidism despite dose reduction.References:[1] McLachlan SM. Rapoport B. Thyrotropin-blocking autoantibodies and thyroid-stimulating autoantibodies: Potential mechanisms involved in the pendulum swinging from hypothyroidism to hyperthyroidism or vice versa. Thyroid. 2013;23(1):14-24.[2] Ohye H, Nishihara E, Sasaki I, et al. Four cases of Graves’ disease which developed after painful Hashimoto’s thyroiditis. Intern Med. 2006;45(6):385-9.
SUN-555 Vitamin E Sequestration by Liver Fat in Vitro and in Women with Hepato-Steatosis
Authors: Violet Pierre-Christian , Ebenuwa Ifechukwude , Wang Yu , Niyyati Mahtab , Padayatty Sebastian , Head Brian , Wilkins Kenneth , Chung Stacey , Thakur Varsha , Ulatowski Lynn , Atkinson Jeffery , Ghelfi Mikel , Smith Smith Sheila , Smith Sheila , Tu Hongbin , Bobe Gerd , Liu Chia-Ying , Herion David , Shamburek Robert , Manor Danny , Traber Maret , Levine Mark Alan 
Published: May 2020

Abstract
BACKGROUND: The global obesity epidemic has sobering consequences to human health. Especially concerning is obesity-associated hepato-steatosis (HS), a common cause of chronic liver disease in the Americas and Western Europe that precedes non-alcoholic steatohepatitis (NASH). Maintenance of normal body weight is the only current means to prevent HS and NASH. We hypothesized that excess liver fat in obesity-associated HS could act as a pathophysiologic chemical depot for fat-soluble vitamins and alter normal physiology. Because clinical trials with Vitamin E (α-T) have shown that NASH partially responds to this supplement, we selected α-T as a model vitamin to test the sequestration hypothesis.
INTERVENTIONS: Under an IND and IRB-approved protocol, two deuterium-labeled α-tocopherols (d3-α-T and d6-α-T) were administered orally and intravenously, respectively, to 10 healthy women and 6 women with HS. Serial blood samples obtained over 72 h were analyzed by LC-MS/MS. In parallel, we performed studies in hepatocytes in cell culture and mouse model.
RESULTS: In healthy women who received oral d3- and intravenous d6-α-T, 85% of the initial plasma peak d6-α-T disappeared within 20 minute and reappeared in the plasma peaking between 6-8 h. Compared to healthy subjects, subjects with HS had similar d6-α-T entry rates into liver, but reduced release rates into plasma (p&lt;0.001). Similarly, pharmacokinetics parameters (AUC and Maximum Concentration [Cmax]), were reduced (AUC0-8,p&lt;0.01;Cmax p&lt;0.02) in HS subjects, indicating reduced hepatic d6-α-T output. Consistently, livers of mice fed with a high fat diet (42% fat) had more vitamin E compared to controls diet (5% fat), with both diets having the same α-T content
CONCLUSION: These findings suggest the unique role of the liver in vitamin E physiology which is dysregulated by excess liver fat (measured by magnetic resonance spectroscopy). Considered together, the findings imply that obesity-associated HS may produce unrecognized hepatic α-T sequestration, which might subsequently drive liver disease. The data here raise the intriguing possibility that timely α-T supplementation might attenuate progression of HS to NASH, perhaps by correcting an unrecognized fat-induced, localized, hepatic vitamin E deficiency prior to onset of inflammation, hepatitis, and fibrosis. Additionally, our findings raise the possibility that HS may similarly alter hepatic physiology of other fat-soluble vitamins.
OR07-05 Is Urinary Calcium the Only Predictor of Nephrolithiasis in Patients with Asymptomatic Primary Hyperparathyroidism?
Authors: Saponaro Federica , Cetani Filomena , Mazoni Laura , Apicella Matteo , Scalese Marco , Pardi Elena , Borsari Simona , Marcocci Claudio 
Published: May 2020

Abstract
The 4th International Workshop for the management of asymptomatic PHPT included, among the criteria for parathyroidectomy, the presence of hypercalciuria (dUCa&gt; 400 mg/day) and increased biochemical stone risk profile.
The aim of the present study was to evaluate the biochemical stone risk profile in 176 consecutive patients (143 females and 33 males) with asymptomatic PHPT. We recorded clinical and biochemical data, including 24 hours urinary measurements of the following parameters: volume and pH, creatinine, calcium, magnesium, sodium, potassium, ammonium, uric acid, oxalate, citrate, phosphate, inorganic sulphate and chloride and kidney ultrasound.
In our cohort dUCa&gt; 400mg/day showed a low sensitivity and positive predictive value (PPV) for nephrolithiasis with high specificity (46.2, 32.7, 73.0% respectively), while hypercalciuria by 4 mg/kg/bw (d-UCa&gt;4mg/kg) had a high sensibility, with low PPV and specificity (79.5, 27.7, 40.1%)
Daily hypomagnesuria (d-HypoMg), but not any other urinary parameter, was an independent predictor of nephrolithiasis in the univariate (OR 2.97 CI 1.27-7.09 P=0.014) and multivariate analyses adjusting for age, sex, BMI, and eGFR (OR 3.13 CI 1.17-8.42 P=0.02). d-HypoMg was relatively lower in the regression analysis with urinary calcium in patients with nephrolithiasis compared with those without. The mean ratio between (dUCa) and (dUMg) was higher in patients with nephrolithiasis compared with those without (4.6±2.0 vs 3.3±4.1; P&lt;0.001). In the univariate and multivariate analyses the dUCa/dUMg ratio was a significant predictor of nephrolithiasis [OR 4.9 (2.3-10.5); P&lt;0.001; OR 5.3 (2.4-11.6), P&lt;0.001, respectively]. The AUC using the dUCa/dUMg ratio as variables was 0.69 (CI 0.60-0.79; P&lt;0.0001). The best cut-off value, set at the highest Youden index, was equal to 4.0, with a sensitivity of 59.0% and a specificity of 77.4%.
In patients with hypercalciuria (&gt;400 mg/24-hour) dUMg was positively correlated with dUCa in those without nephrolithiasis (r=0.50, β=0.2, P=0.002) but not in those with nephrolithiasis (r=0.05, β= 0.014; P=0.8). In patients without hypercalciuria we found that hypomagnesuria remained a predictor of nephrolithiasis using either 400 mg/die (P=0.002, OR 5.12 (1.84-14.24) or 4 mg/kg bw (P=0.014, OR 6.24 (1.45-26.8). Moreover, the OR for nephrolithiasis improved using the combination of d-HypoMg with d-UCa&gt;4mg/kg (OR 8.12, CI 1.92-34.18, P=0.004), but not with dUCa&gt; 400mg/day.
The current urinary calcium threshold of &gt;400 mg/24-hour has a low sensitivity in detecting nephrolithiasis; our data suggest that sensitivity, specificity and positive predictive value could be improved including dUMg, dUCa/dUMg ratio and the combination of d-HypoMg with d-UCa&gt;4mg/kg in the stone risk evaluation.
SUN-542 The Effect of Energy Deprivation on Metabolic Hormone Responses to Meals
Authors: Shekhar Skand , Leka Helen , Kim Anne , Purse Bona , Hersch Katie R , McGee Christopher , McGrath John , Smith-Ryan Abbie E , Hall Janet Elizabeth 
Published: May 2020

Abstract
Background: Intermittent caloric restriction (ICR) has recently gained popularity as a weight-loss strategy; however, fasting metabolic hormones and dynamic meal-related responses, are not well-established in this setting. Methods: We measured metabolic hormone responses to 5-days of neutral or decreased energy availability (NEA, 45 kcal/kg LBM*d vs DEA, 20 kcal/kg LBM*d) in the early follicular phase (EFP) in 19 regularly-cycling, sedentary, women (age 23.36± 2.08 yr; mean±SD). Hunger was assessed using a visual analogue scale on the 5th day of each condition. Scheduled breakfast and lunch were administered according to assigned caloric intake, while an afternoon snack based on NEA was provided on both occasions. Blood was sampled for leptin, insulin, glucose, and GH at 10-min intervals and cortisol was measured at 30-min intervals over eight hours starting at 0800 h, while Orexin A and adiponectin were measured in fasting samples. AUC for each hormone for every meal and diet condition were analyzed using linear mixed models. Insulin and insulin/glucose ratio (I/G) were also adjusted for meal calories. Percentage body fat mass was measured every visit using air displacement plethysmography (BodPod®). Results are presented as least square mean ± sem. Results: There were no differences in body mass index or % fat mass after NEA vs DEA although there was a significant increase in hunger with DEA (p=0.002). Fasting levels of glucose and insulin were unchanged while leptin decreased with DEA (1.27±0.07 and 1.04±0.07 ng/mL, NEA and DEA respectively; p&lt;0.0001), and Orexin A increased (0.55±0.04 and 0.60±0.04 ng/mL; p=0.04). The AUC for glucose was lower with DEA across all meals (p&lt;0.0001). Insulin, I/G and I/G normalized for ingested calories (nI/G) decreased in response to DEA (p&lt;0.005, p&lt;0.05 and p&lt;0.0001). The slope of the increase in leptin across the day was not different between NEA and DEA (p=0.20). Adiponectin, GH and cortisol were unaffected by DEA. Conclusion: These studies indicate that although fasting glucose and insulin are unaffected by short-term caloric restriction, the insulin response to glucose is attenuated even when adjusting for meal-related calories. Orexin A increased and leptin decreased with reduced caloric intake, acting, at least in part, to stimulate appetite. Taken together, these hormonal responses, directed at preserving energy homeostasis, have important implications for understanding the potential efficacy of intermittent caloric restriction.
SUN-515 Use of Plasmapheresis for Treatment of Thyroid Storm Resistant to Antithyroidals
Authors: Vega Myrian Noella Vinan , Mejia Ana Marcella Rivas , Nugent Kenneth 
Published: May 2020

Abstract
Management strategies of thyroid storm include measures to reduce thyroid hormone synthesis, hormone release, conversion from T4 to T3, and inhibition of the peripheral effects of excessive thyroid hormone. Plasmapheresis has been described as a treatment option when traditional therapy is not successful or not feasible.
We present a case of an adult patient who presented in thyroid storm in whom plasmapheresis was used successfully as a bridge to thyroidectomy.
51-year-old female with history of hypertension presented with sudden onset shortness of breath, and palpitations. She had an irregular heart rate of 140BPM, respiratory rate of 40, mean arterial blood pressure 65mmHg. Electrocardiogram confirmed atrial fibrillation with rapid ventricular response and the patient was admitted to the intensive care unit. She was started on diltiazem drip and subsequently received amiodarone and electrical cardioversion due to persistent rapid heart rate. She developed respiratory distress and required endotracheal intubation.
Initial thyroid profile revealed low TSH and normal FreeT4, but her FT4 increased above normal on day 2, treatment for thyroid storm was initiated with potassium iodine, hydrocortisone and propylthiouracil. She was kept on propranolol 80 mg q/4h, intravenous esmolol 50 mcg/kg/min, diltiazem drip 5 mg/hr, and was started on Digoxin 0.25 mg q/4h. TSI and TPO were undetectable, and thyroid ultrasound revealed a right nodule measuring 5 x 2.2 x 3.7cm. Thyroid storm was attributed to a toxic nodule exacerbated by exposure to excess iodine (contrast for imaging and amiodarone). Propylthiouracil, hydrocortisone and beta blocker were maximized, and cholestyramine was added, but their heart rate remained elevated, blood pressure worsened requiring synchronized cardioversion.
Because of persistent hyperthyroid state, refractory to medical treatment, patient was started on plasmapheresis on day 10 of hospitalization, she underwent 5 sessions with significant reduction in Free T3 and Free T4 (Figure 1), and remarkable improvement in her hemodynamic status and resolution of tachycardia. Patient underwent total thyroidectomy on day 16, without complications.
Plasmapheresis has been described as a treatment option for refractory thyroid storm, as a bridge therapy prior thyroidectomy. During plasmapheresis, thyroid-binding globulin, thyroid hormones, cytokines and putative antibodies are removed with the plasma; then the colloid replacement provides new binding sites for circulating free thyroid hormone (2). Although albumin binds thyroid hormone less avidly than TBG, it provides a much larger capacity for low-affinity binding that may contribute to lower free thyroid hormone levels, providing a window for thyroidectomy.
1.
Muller C et al, Role of Plasma Exchange in the Thyroid Storm, Therapeutic Apheresis and Dialysis15 (6): 522–531
SUN-636 Gaps in Quality of Delivery of Post-Partum Care in Preconception Counselling for Pregnant Women with Pre-Existing Diabetes at a Large Academic Tertiary Centre
Authors: Abbas Minan , Feig Denice , Mukerji Geetha 
Published: May 2020

Abstract
BACKGROUND: Women with pre-existing diabetes are at increased risk of serious adverse pregnancy outcomes compared with the general maternity population including congenital anomaly, stillbirth and neonatal death. The 2018 Diabetes Canada Clinical Practice Guidelines (DC CPG) on Diabetes in Pregnancy recommend that women with pre-existing diabetes are provided with postpartum and preconception counseling by their diabetes healthcare team, as this is associated with improved maternal and fetal outcomes.
OBJECTIVE: To evaluate the quality of physican counselling of post-partum management and pre conception advice for women with pre-existing diabetes who receive their intrapartum care at Mount Sinai Hospital Diabetes in Pregnancy Clinic in Toronto Ontario.
METHODS: Eligible patients were pregnant women with pre-existing Type 1 and Type 2 diabetes who were followed in pregnancy until their 6 weeks postpartum clinic visit. Consecutive baseline chart review of patients between June 2018 - June 2019 was performed to audit documentation of physician counselling of DC CPG recommendations at the 6 week post-partum visit. Key components of the recommendations included: 1) targeting an HbA1c of &lt;7% pre-pregnancy, 2) folic acid supplementation and neural tube defect prevention, 3) weight management and optimization of BMI, 4) contraceptive measures and family planning, 5) information regarding outcomes and risks for mother and baby 6) yearly retinal exam.
RESULTS: Results of our chart review found that 42% (n=50) of women with pre-existing diabetes who received their intrapartum care at our clinic returned for their 6 week postpartum visit between June 2018-June 2019. Audit of the 6 week post-partum clinic note found that less than 20% of women had physician documentation of counselling on two or more key components of the DC CPG recommendations (1-6).
CONCLUSION: There is a large gap in women attending postpartum appointments and there are significant gaps in physician documentation of counselling among women with pre-existing diabetes. Further analysis will be conducted in order to determine if there is a patient knowledge gap regarding counselling recommendations and a quality improvement project will be undertaken to close this gap.
SAT-685 Euglycemic Diabetic Ketoacidosis in T1d: The Era of SGLT-2 Inhibitors and Keto-Diet
Authors: Castellanos-Diaz Jessica , Mathews Sherin Elsa , Barsamyan Gayane , Julio Leey-Casellas , Kadiyala Sushma 
Published: May 2020

Abstract
Introduction Euglycemic diabetic ketoacidosis (DKA) is a challenging diagnosis since near normal blood sugar levels can be misleading. In the present case, we describe a patient with Type 1 Diabetes (T1D) on SGLT2 who underwent a strict low carb diet. Case Report A 70-year-old female with past medical history of unspecified diabetes mellitus and primary hypothyroidism presented to emergency room complaining of nausea and dizziness of four days with decreased oral intake. She was alert and oriented, normal weight (52 kg, BMI 20 kg/m2) with stable vital signs, except for mild tachypnea (22/min). Initial labs showed serum glucose 136 mg/dL, bicarbonate 10 mmol/L (normal 20-31), anion gap of 27, venous blood gas pH 7.1, B-hydroxybutyrate 8.8 mmol/L (normal 0.02-0.27), glucosuria &gt; 500 mg/dL, and moderate ketonuria. Screening for ethyl alcohol and ethylene glycol was negative. Lactic acid, cardiac enzymes, renal and liver function tests were normal. She was diagnosed with diabetes mellitus at age 37, on insulin since then. No alcohol use. Her new primary care physician found an A1C of 9.0% for which metformin 1000mg oral twice a day and empagliflozin 12.5 mg oral daily were added and aspart insulin was discontinued. Daily glargine remained at 20 units daily. She was advised to lose weight for which she started a keto-diet 4 weeks prior to this presentation. She had lost 15 pounds since then accompanied by polyuria and polydipsia. Upon admission, she received IV insulin and IV fluids. An endocrinology consultation was requested for euglycemic DKA secondary to SGLT2 complicated by starvation ketosis. Antibodies against glutamic acid decarboxylase were positive at 250 IU/mL (normal &lt; 5). She was discharged on glargine, aspart insulins and oral medications were discontinued. Conclusion This case shows the importance of identifying the specific type of diabetes for appropriate individualization of therapy. Following a keto-diet in unrecognized T1D can trigger ketoacidosis in the setting of SGLT2 inhibitors leading to euglycemic diabetes ketoacidosis.