bluuebunny/crossref_metadata_2025_split huggingface dataset:
MON-LB105 Resident Obesity Management: Comfort Correlates With Action
Authors: Hoppenfeld Mita Shah , Abou-Arraj Nadeem E , Hauser Michelle E 
Published: May 2020

Abstract
The projected prevalence of obesity in the US is 50% by 2030.1 Little data exists on resident physician obesity management in their primary care clinics.2 We aimed to explore internal medicine (IM) resident comfort, knowledge, and treatment practice of obesity in primary care.
IM residents at one academic medical center (N=125), at 5 primary care sites were anonymously surveyed about knowledge, comfort, and practice behaviors around obesity management. In this exploratory analysis, respondents self-reported comfort with lifestyle counselling and weight management medication (WMM) prescription on 4-point Likert scales; scores were combined into an overall Comfort Score (CS). Correlation analysis (Pearson’s correlation) compared CS with the following Clinical Actions: referral to lifestyle specialists, lifestyle counseling, WMM prescription, and bariatric surgery referral.
The response rate was 70/125 (56%). Most residents (91%) reported discomfort with prescribing WMMs and most (84%) had never prescribed one. While most residents (81%) were “comfortable” or “somewhat comfortable” with lifestyle counseling, only 33% reported consistently providing it. Of the 31% of residents that correctly identified indications for bariatric surgery, only 9% reported referring patients they considered appropriate for surgery. Notably, a higher CS was significantly correlated with more frequent bariatric surgery referrals (r = 0.29; p = 0.015), lifestyle counselling (r = 0.33; p = 0.004), WMM prescription (r = 0.32; p=0.006), and lifestyle specialist referral (r = 0.25; p = 0.035). Reported barriers to lifestyle counseling were lack of time (93%), poor familiarity with resources (50%), and lack of training in motivational interviewing (36%). Barriers to WMM prescription were unfamiliarity with the medications (84%) and side effect concerns (61%). Finally, 90% desired more training in pharmacotherapy, and 77% wanted more information on referral processes for surgical and medical interventions.
Most residents surveyed do not feel adequately prepared to provide evidence-based management of obesity via lifestyle changes counseling, WMM prescription, or specialty care referral. Comfort and knowledge of system processes/resources and WMMs are critical to resident management of obesity. These are potential targets for educational intervention in residency curricula that may improve care for patients with obesity.
Citations: 1. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019;381(25):2440-2450. doi:10.1056/NEJMsa19093012. Huang J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicians’ Weight Loss Counseling in Two Public Hospital Primary Care Clinics. Acad Med. 2004. doi:10.1097/00001888-200402000-00012
MON-LB125 Dka From a Ketogenic Diet and Intermittent Fasting or Ketosis-Prone Diabetes?
Authors: Athonvarangkul Diana , Gossmann Mona , Cohen Kenneth 
Published: May 2020

Abstract
Background: Ketogenic diets and intermittent fasting (IF) are popularly used for weight loss. Generation of ketone bodies for fuel from fatty acid oxidation underlies both diets, combined or separately. We present a case of a prediabetic patient admitted for DKA after starting a combination keto/IF diet. Clinical Case: A 63-year-old man with hypertension, prediabetes, and alcohol use was admitted from clinic after receiving lab test results consistent with diabetic ketoacidosis (DKA). Two months ago, he had started a keto diet with IF (5 days/week, 18 hour fast/day) and achieved weight loss of 20 pounds. He reported polyuria and polydipsia, which was attributed to the recent initiation of chlorthalidone. Laboratory testing revealed glucose 519 (&lt;/= 199 mg/dL), bicarbonate 12 (20-30 mmol/L), creatinine 1.6 (0.5-1.5 mg/dL), anion gap of 23 (6-16 mEq/L), HbA1c 12.2% (4-5.6%), c-peptide 1.37 (0.80-3.85 ng/mL) with glucose 294, GAD65 Ab &lt;5 (&lt;5 IU/mL), IA2 Ab &lt;5.4 (&lt;5.4 U/mL), Insulin Ab &lt;0.4 (&lt;0.4 U/mL), triglyceride 546 (0-199 mg/dL), LDL-d 176 (0-129 mg/dL), cholesterol 310 (0-199 mg/dL) and HDL 39 (&gt;/= 40 mg/dL). Workup for precipitating causes of DKA was negative including normal lactate, lipase and troponin. The patient was managed with an insulin drip and discharged on subcutaneous insulin (Lantus 45 units/day, Aspart 13 units with meals) and metformin. The patient re-introduced carbohydrates into his diet after meeting with the nutritionist. Eight weeks later, the HbA1c decreased to 6.6% and insulin was significantly reduced to Lantus 25 units/day. Sixteen weeks after discharge, the HbA1c further declined to 5.1% and Lantus was reduced to 10 units/day. Beta cell function at that time was preserved as evidenced by c-peptide 1.82 ng/mL. Insulin therapy was discontinued and the patient was closely monitored for urinary ketones and recurrence of hyperglycemia, neither which have developed. Conclusion: This is a unique case of DKA precipitated by a keto/intermittent fasting diet, without the use of SGLT2 inhibitor. Interestingly, previous metabolic studies show that nutritional ketosis typically generates low levels of serum ketones without a clinically significant anion gap metabolic acidosis. With negative beta cell autoantibodies and preserved beta cell function, this presentation is also consistent with ketosis-prone diabetes type 2B. It is possible that nutritional ketosis triggered the onset of KPD, although the mechanism remains unclear particularly since it is known that lipotoxicity is not pathogenic in the development of KPD. References: 1. Bueno NB et al. Br J Nutr. 2013;110(7):1178-1187. 2. Cahill GF Jr. Annu Rev Nutr. 2006;26:1-22. 3. Gaba R et al. Expert Rev Endocrinol Metab. 2019;14(1):43-48.
MON-LB7 Assessment of Endothelial Dysfunction by Flow Mediated Dilation in Postmenopausal Women
Authors: Chopra Seema , Sharad Piyushi , Bahl Ajay , Sikka Pooja 
Published: May 2020

Abstract
Menopause is defined by the World Health Organization as the permanent cessation of menses as a result of the loss of ovarian follicular Function or surgical removal of ovary. Menopausal health demands priority in Indian scenario due to increase in life expectancy and growing population of menopausal women. It is well known that cardiovascular risk is higher in postmenopausal women than in premenopausal women, but it is unclear how much of the elevated risk is related to aging, menopause itself or presence of other confounding factors. Endothelial dysfunction is one of the most important predictors for determining early atherosclerotic risks as it precedes overt vascular disease by years and may itself be a potentially modifiable risk factor. Although no gold standard for the measurement of endothelial function exists, the measurement of flow mediated dilation (FMD) in the brachial artery, assessed with Doppler ultrasonography, is the most studied method and seems most promising for clinical application.objective - To compare effect of menopause on endothelial dysfunction by brachial artery flow mediated dilation (BAFMD) in postmenopausal women versus menstruating non-diabetic, non-obese females of same age group. Methodology: We conducted a case control study in Departments of Obstetrics & Gynaecology and Cardiology, PGIMER, Chandigarh.Subjects were menopausal women between 45- 55 years of age.Controls included the women of same age group who had not attained menopause.To detect a statistical significant difference of approximately 4-8% between cases and controls,50 women were recruited in both groups with a power of 90% and confidence interval of 95%. The study was approved by the ethics committee of the institute. Effect of menopause on BAFMD, NMD (nitro-glycerine mediated dilation), FRS (Framingham Risk score) and individual components of FRS was studied.Results: A statistically significant negative correlation was found between BAFMD and FRS, BAFMD and age and BAFMD and duration of menopause.On studying the effects of FRS, individual components of FRS and duration of menopause on smooth muscle function, statistically significant negative correlation was found between NMD and FRS and NMD and AgeConclusion:It was concluded that the menopausal status does not affect endothelial function in women who are at low risk of cardiovascular disease but it affects the vascular smooth muscle function. We also found significant correlation between FMD and NMD (p = 0.00) signifying that both endothelial dysfunction and vascular smooth muscle dysfunction are inter-related. On evaluating the strength of correlation of FMD with FRS, different parameters of FRS and duration of menopause, FMD was found to have a statistically significant negative correlation with all these parameters.
MON-LB79 Do Ultrasound Patterns and Clinical Parameters Modify the Probability of Thyroid Cancer Predicted by Molecular Testing in Thyroid Nodules With Indeterminate Cytology?
Authors: Figge James J , Gooding William E , Burman Kenneth D , Mayson Sarah , Scheri Randall P , Sipos Jennifer A , Sippel Rebecca S , Steward David L , Yang Samantha Peiling , Yip Linwah , Nikiforov Yuri E , Carty Sally E 
Published: May 2020

Abstract
Background: Molecular testing (MT) is commonly used to refine cancer probability in thyroid nodules with indeterminate cytology. Whether or not ultrasound (US) patterns and clinical parameters can further modify the risk of cancer in nodules predicted to be positive or negative by molecular testing remains unknown. Aim: To test if clinical parameters, including age, gender, nodule size (by US), Bethesda category (III, IV, V), US pattern (American Thyroid Association [ATA] system vs American College of Radiology TIRADS), radiation exposure, and family history of thyroid cancer (TC) can modify the probability of TC or NIFTP predicted by MT in thyroid nodules with indeterminate cytology. Methods: We studied 257 thyroid nodules from 10 study centers with fine-needle aspiration (FNA) yielding indeterminate cytology and informative MT results using the ThyroSeq v3 genomic classifier (TSv3). Univariate and multivariate logistic regression were used for data analysis. Results: In this group of thyroid nodules, out of all parameters studied using univariate regression, patient gender, age, and Bethesda category were significantly associated with TC/NIFTP probability (P&lt;0.05 for each). The ATA US patterns showed a positive trend (P=0.1211), whereas TIRADS was not predictive (P=0.3135). A multivariate regression model incorporating the four most informative covariates (gender, age, Bethesda category, and ATA US patterns) (model #1) yielded a C index=0.653; R2=0.108. Male gender and Bethesda category V significantly increased risk, and age demonstrated a nonlinear risk profile. When TSv3 was added to model #1, the C index increased to 0.888; R2=0.572. However, age (P=0.341), Bethesda category (P=0.272), and the ATA US patterns (P=0.264) had limited predictive ability in comparison with TSv3, which dominated the predictive performance (P&lt;0.001). Gender was the only parameter showing tendency for significance beyond MT (P=0.095). The most parsimonious model incorporated gender and TSv3 (C index=0.889; R2=0.588). Conclusions: While often useful in selecting thyroid nodules for FNA, neither the ATA US nor the TIRADS scoring systems were informative in further predicting TC/NIFTP in thyroid nodules with indeterminate FNA cytology. Although age and Bethesda category were associated with TC/NIFTP probability on univariate analysis, they had limited incremental value above the high predictive ability of TSv3. Gender was the only parameter with potential contribution to predicting TC/NIFTP in addition to MT.
SUN-033 A Rare Case: Bone Pain and Continued Linear Growth in a Young Adult Male Due to Aromatase Deficiency
Authors: Lee Ju-Hao , Lee Ni-Chung , Tung Yi-Ching 
Published: May 2020

Abstract
Introduction:
Aromatase, the product of CYP19A1, catalyzes the conversion of androgens to estrogens. 46, XX infants with aromatase deficiency, due to androgen excess, present with ambiguous genitalia at birth. In 46, XY individuals, however, the subtle phenotypic features make the diagnosis even more difficult. Less than 15 male cases were reported in the literature and we present the first case of aromatase deficiency diagnosed in Taiwan.
Clinical Case:
A 23-year-old man, Burman overseas student of Chinese descent, presented to an orthopedist with a two-year history of left ankle pain, which was diagnosed as gout by his previous physician. Unexpectedly, unfused growth plates were discovered so he was referred to our pediatric endocrine clinic for evaluation. Reviewing his past history, we learned he is the third child of consanguineous parents. His mother experienced deepening of voice during this pregnancy which resolved following parturition. He was 177 cm tall at the age of 19. At the time he presented to our clinic, he weighed 95.3 kg and was 183 cm tall. Physical exam showed the ratio of U/L segment to be 0.82, stretched penile length 6.5 cm, bilateral testes &gt; 25 mL, pubic hair at Tanner stage V, and presence of genu valgum. The skeletal age was 14 years and 6 months. Labs showed FSH 19.7 IU/L (0.7–11.1), LH 8.18 IU/L (0.8–7.6), total testosterone 1335 ng/dL (240–871), estradiol &lt;20 pg/mL, DHEA-S 13.41 μmol/L (6.5–14.6), androstenedione 5.73 nmol/L (3.5–9.8) and 17-OH progesterone 6.55 nmol/L (2–10). GnRH (100 μg i.v) stimulation test showed a supranormal basal FSH level and a normal to higher LH response (FSH at baseline/peak were 23.0/38.6 IU/L; LH at baseline/peak were 8.81/47.7 IU/L). Under the clinical suspicion of aromatase deficiency, we performed genetic sequencing of CYP19A1 (NM_031226) and found a homozygous missense variant c.1108G&gt;A (V370M), a previously reported pathogenic mutation.
A diagnosis of aromatase deficiency was made. He also had hypertension (156/87 mmHg), dyslipidemia (T-cholesterol 236 mg/dL, LDL-C 175 mg/dL) and insulin resistance (AC glucose 87 mg/dL, insulin 23.5 μU/mL, HOMA-IR 5.0, Hb1Ac 5.6%). Bone mineral density of lumbar spine (DXA) showed a T-score of -2.8, consistent with the diagnosis of osteoporosis.
Conclusion:
Estrogen is pivotal for epiphyseal closure in both sexes. As demonstrated in this case, estrogen deficiency in men results in tall stature and eunuchoid habitus, while it is also associated with low bone density and metabolic syndrome. The gonadotropin response in this report suggests the inhibitory role of estrogen in the male HPG axis. Clinicians may consider this rare diagnosis for men in their late teens or early twenties, who have spontaneous initiation of puberty, presenting with bone pain and continued linear growth.
MON-LB040 Challenge in Diagnosing and Treating of Mediastinal Paraganglioma
Authors: Alomair Basil , Jammah Anwar 
Published: May 2020

Abstract
Paraganglioma is a rare type of neuroendocrine tumor of the autonomicnervous system.1 It is extremely rarely present in mediastinum (less than2%).2Case report We report a 43 years-old woman, she was referred to our clinic with ahistory of high blood pressure (BP) for two years, accompanied by spellsof sweating, headache, anxiety and palpitation. She was provisionaldiagnosed with essential hypertension and was on four medications onmaximum dose.The patient declined any previous surgical history, and review of systemswas unremarkable. On examination, she was conscious and alert. Her vitalsigns were within normal limit. She reported to our clinic with homereadings of BP ranging from 150-180 mmHg systolic and 90-100 mmHgdiastolic.Initial investigations of basic chemistry, renal profile, hormonal profile,aldosterone, and renin were within the normal range.Serum Normetanephrine was 800 ng/L (normal &lt; 180 ng/L), 24 hoursurine of Normetanephrine was 5205 microgram/24 hours (normal &lt; 600microgram/24 hours), and 24 hours urine Metanephrine was withinnormal. CT scan of the adrenal and MRI abdomen showed normal adrenalglands and no mass in the abdomen. MIBG scan was normal for the wholebody. An unusual location of the Paraganglioma was suspected, andfurther images were carried on. A CT chest showed 4x4 cm posteriormediastinal mass in area of Aortopulmonary window, adherent toposterior wall of Aorta and pulmonary artery. Positron EmissionTomography (PET) scan was done prior to the surgery.Surgical resection of the mass with reconstruction of both pulmonaryartery and pericardium was done without any complications. Moreover,histopathology confirmed the diagnosis of Paraganglioma.The patient was followed up with a CT scan six months post-operativelyas an outpatient, along with 24-hour urine Metanephrine and Normetanephrine. All labs and imaging were normal. The patient hadanother Normetanephrine measurement twelve months later and it wasnormal. Now, she has been followed for seven years with no moresymptoms and normal BP readings. All of her antihypertensive agentswere discontinued. ConclusionWe experience an unusual location of Paraganglioma at the mediastinum,which is representing less than 2% of all Paraganglioma. However, in thepresence of characteristic of Paraganglioma symptoms, a thoroughassessment should be carried out and such location of mediastinumshould be suspected and investigated.References:1. Institute NC. Pheochromocytoma and Paraganglioma Treatment(PDQ®)-Health Professional Version. https://www.cancer.gov/types/pheochromocytoma/hp/pheochromocytoma-treatment-pdq. Published 2019. Accessed February 1, 2020.2. Paraganglioma: An Uncommon Cause of Mediastinal Mass. -PubMed - NCBI. https://www.ncbi.nlm.nih.gov/pubmed/32000513.Accessed February 1, 2020.
SAT-LB49 Persistent vs Recurrent Cushing’s Disease Diagnosed Four Weeks Post-Partum
Authors: Nosova Emily V , Bederson Joshua B , Cheesman Khadeen Christi 
Published: May 2020

Abstract
Background: Cushing’s disease (CD) recurrence in pregnancy has previously been described and is thought to be associated with predictable estradiol fluctuations during gestation. CD recurrence in the immediate post-partum period has been reported once, but never in a patient with documented dormant disease during pregnancy.Clinical Case: A 30 year old woman with recently diagnosed pre-diabetes presented with weight gain, dorsal hump, depression, oligomenorrhea, and lower extremity weakness. Diagnostic tests were consistent with CD. Results included: three elevated midnight salivary cortisols: 0.33, 1.38 and 1.10 ug/dL (&lt;0.010 - 0.090); 1-mg dexamethasone suppression test (DST) with cortisol 14 ug/dL (&lt;1.8); elevated 24-hr urine cortisol 825 ug/24 hr (6-42); and ACTH 35 pg/mL (7.2-63.3). MRI of the pituitary gland revealed a left 4mm focal lesion. After transsphenoidal resection (TSA), day 1, 2, and 3 morning cortisol values were 18, 5, and 2 ug/dL, respectively. Pathology did not show a definitive pituitary neoplasm. She was rapidly titrated off hydrocortisone (HC) by six weeks post-resection. Her symptoms steadily improved. She resumed normal menses and conceived unexpectedly around 3 months post-TSA. She complained of severe fatigue in her late 2nd trimester. Given low 24-hr urine cortisol of 15 ug/24 hr at 36 weeks gestation, she was started on HC. She was induced at 40 weeks gestation for oligohydramnios and subsequently delivered a healthy baby boy. HC was discontinued immediately after delivery. Around four weeks post-partum she developed symptoms concerning for CD. Diagnostic tests showed elevated midnight salivary cortisol of 0.206 and 0.723 ug/dL and 24-hour urine cortisol of 400 ug/24 hr. MRI pituitary illustrated a 3mm adenoma in the left posterior gland which was thought to represent growth of residual tumor not clearly seen on post-op MRI. During repeat TSA, a discrete lesion was found and resected. Pathology confirmed corticotroph adenoma with MIB-1 &lt; 3%. Post-operative day 1, 2, and 3 cortisol levels were 26, 10 and 2.8 ug/dL, respectively. She was tapered off HC within one month. Her symptoms improved only slightly and she continued to report weight gain, muscle weakness, and fatigue. Three months after repeat TSA, biochemical data showed 1 out of 2 midnight salivary cortisols elevated at 0.124 ug/dL and elevated urine cortisol of 76 ug/24 hr. MRI pituitary demonstrated a 3 x 5 mm left enhancement, concerning for residual or enlarged persistent tumor. Conclusion: We describe the first report of recurrent CD that was quiescent during pregnancy, and subsequently diagnosed in the immediate post-partum period. Treatment options for persistent or recurrent CD include aggressive surgical resection, radiation and/or medical therapy. In the context of additional family planning for this otherwise healthy, reproductive-age woman, ideal management options remain uncertain.
MON-215 Clinical Factors Associated with Insulin Secretion and Sensitivity in Patients with Primary Aldosteronism
Authors: Tsurutani Yuya , Katsuragawa Sho , Takiguchi Tomoko , Saito Jun , Omura Masao , Nishikawa Tetsuo 
Published: May 2020

Abstract
Introduction: Primary aldosteronism (PA) is associated with an increased risk of impaired glucose tolerance or type 2 diabetes mellitus. Previous studies have reported that impaired insulin secretion and insulin sensitivity in PA may lead to impaired glucose tolerance. However, the relationship between PA and glucose tolerance, and the factor associated with these glucose metabolism abnormalities is not well understood. In particular, few studies have analyzed the association between aldosterone excess and insulin sensitivity or resistance after the adjustment for other clinical variables. In this study, we analyzed the associations between multiple clinical variables observed in PA and the indices of insulin sensitivity and resistance, using the result of 75 g oral glucose tolerance test (OGTT).Method: This was a retrospective observational study that analyzed the data of 646 patients with PA who underwent adrenal venous sampling and 75 g OGTT. The insulinogenic index and Matsuda index, indices of insulin secretion and sensitivity, respectively, were calculated from the results of a 75 g OGTT. Correlations between these indices and the multiple clinical variables were analyzed. In addition, we performed multiple regression analyses to identify the independent explanatory variables of these indices.Results: Insulinogenic index had positive correlations with the body mass index (BMI), alanine aminotransferase (ALT) level, triglyceride (TGL) level, and potassium level, and negative correlations with both age and plasma aldosterone concentration (PAC). In a multiple regression analysis, both the age (β = -0.231, p &lt; 0.001) and potassium level (β = 0.175, p = 0.002) were selected as the independent explanatory factors. The Matsuda index had positive correlations with the PAC and cortisol level after a 1 mg dexamethasone suppression test (DST), and negative correlations with BMI, ALT level, TGL level, plasma renin activity (PRA), and potassium level. In a multiple regression analysis, BMI (β = -0.216, p &lt; 0.001), ALT level (β = -0.290, p &lt; 0.001), TGL level (β = -0.225, p &lt; 0.001), the cortisol level after 1 mg DST (β = 0.124, p = 0.009), and PRA (β = -0.119, p = 0.019) were selected as the independent explanatory factors.Conclusion: In PA patients, older age and decreased potassium levels were associated with impaired insulin secretion. An increase in the variables associated with metabolic abnormalities such as BMI, ALT, and TGL were associated with decreased insulin sensitivity. In addition, we found that decreased PRA was associated with increased insulin sensitivity.