bluuebunny/crossref_metadata_2025_split huggingface dataset:
MON-LB64 Primary Hyperparathyroidism With Severe Hypercalcemia During Pregnancy: A Challenging Diagnosis and Management
Authors: George Gemy M , Slotcavage Rachel L , Ambrogini Elena 
Published: May 2020

Abstract
Background:Primary Hyperparathyroidism (PHPT) is rare in pregnancy and the physiological adaptations in mineral and skeletal homeostasis that occur during gestation need to be taken into consideration for the diagnosis and management. Clinical case:A 30-year-old primgravid woman with history of kidney stones presented at our institution during the 13th week of twin gestation with severe nausea and vomiting. She had previously been hospitalized at 9 weeks for hypercalcemia and acute kidney injury, and treated with steroids for presumed granulomatous disease without improvement. She was on prenatal vitamins and family history was significant for kidney stones, but not hypercalcemia. At admission, calcium was 14.4 mg/dl, ionized calcium 1.89 mmol/L (1.16-1.32), PTH 15.2 pg/ml (12-88), albumin 3.4 g/dl, phosphorus 2.1 mg/dl, and creatinine 1.8 mg/dl. PTHrP was &lt;2 pmol/L (&lt;4.2) and 1, 25-dihydroxyvitamin D was 191 pg/mL (2nd trimester range 72-160 pg/ml). She was treated with IV hydration, but her calcium remained elevated and severe hypercalcemia recurred after stopping hydration. She underwent neck exploration and right upper parathyroidectomy in the second trimester. The other parathyroid glands were noted to be normal. Intraoperative PTH dropped from 25.2 pg/mL to 4.4 pg/mL. Final pathology showed a hypercellular parathyroid. Her calcium dropped to normal levels in the early postoperative period. Calcitonin was initiated by another provider two weeks postoperatively for persistent mild hypercalcemia. Her calcium levels remained at the upper limit of normal during her 2nd and 3rd trimesters. PTH remained suppressed at 3.2 pg/ml. She had a C-section at 34 weeks for premature rupture of membranes. Her twins did not develop hypocalcemia or hypoparathyroidism. The most recent postpartum calcium was 9.2 mg/dl with PTH 3.3 pg/ml.Conclusions:Our case highlights the challenge in the diagnosis and management of PHPT in pregnancy. During pregnancy, PHPT is diagnosed by elevated ionized or albumin corrected calcium and non-suppressed PTH level. It is important to note that 1,25-dihydroxyvitamin D levels physiologically increase in the second and third trimester. Since both PHPT and pregnancy cause intestinal calcium absorption and bone resorption, PHPT during pregnancy has increased risk of severe hypercalcemia, pancreatitis and renal stones. During the third trimester the transfer of calcium through the placenta and the uptake of calcium by the fetal skeleton can protect against severe hypercalcemia. However, hypercalcemic crisis can occur because of the peak release of PTHrP by the placenta and breasts, or after delivery due to loss of calcium transfer to the placenta. Parathyroidectomy is preferably performed in the second trimester to reduce fetal and maternal complications. After delivery neonatal hypocalcemia can have a delayed onset, a prolonged course and could be permanent.
MON-LB301 Application of Lean Six-Sigma DMAIC Tool for Improvement and Sustainability of Diabetes Management in Outpatient Clinics
Authors: Bernuy Mario C Rivera , Usha Kollipara , Burks Jessica , Fish Jason , Ali Sadia 
Published: May 2020

Abstract
DMAIC: Define, Measure, Analyze, Improve, Control. LSL: Lower specified limit. USL: Upper specified limit.
Lean Six Sigma DMAIC is quality improvement methodology used for strategic business management. Frequent applications of this methodology in healthcare include improvement of patient satisfaction, reduction of emergency department waiting times, prescription error reduction and monetary recovery by reducing waste.
Patients with a HgbA1c testing frequency of &gt;6 months have poorer glycemic control. The American Diabetes Association recommends HgbA1c test quarterly in patients whose therapy has changed or who are not meeting glycemic goals and at least two times a year in patients who are meeting treatment goals.
We hypothesized that the Lean Six-Sigma DMAIC tools can be used in the outpatient clinic setting to improve frequency of HgbA1c testing in patients with diabetes mellitus.
At baseline, 19% of our patients with diabetes mellitus had HgbA1c tested infrequently, defined as more than 6 months. This high percentage is a concern as it could lead to poor diabetes control. The aim was to increase percentage of patients having an HgbA1c tested between 3 to 6 months before an appointment in our clinic, to a goal of 90%. Target population included all patients with diabetes mellitus seen in outpatient endocrinology clinic.
A baseline analysis of existing processes was done through brainstorming with the clinic staff using a fish bone diagram. Lack of follow up and HgbA1c testing orders were some of the modifiable factors identified. The new processes implemented include nurse driven standing medical orders for HgbA1c testing and pre-visit planning. Control phase included regular audits to sustain the improvements.
The percentage of patients with a HgbA1c testing within 3-6 months of appointment improved from a baseline of 76.7% (LSL:70%, USL:94%) to 92.2% (LSL:88%, USL:93.7%). The improvement was noticeable within 1 month of new process implementation and continues to sustain. The mean had an absolute improvement of 15.5%. The variation from the mean decreased from 25% at baseline to 6% at the end of the control phase. The reduction in variation made our future results more predictable.
The use of Lean Six-Sigma DMAIC quality improvement tools are an effective method to improve quality of care in the outpatient setting. These strategies can be replicated for other clinical quality outcomes.
MON-LB104 Update on Anti-Obesity Medical Devices
Authors: Heshmati Hassan M 
Published: May 2020

Abstract
Background: Obesity is excess body weight for a given height. It is a worldwide pandemic associated with increased morbidity/mortality and high cost for the society. The prevalence of obesity has doubled in more than 70 countries since 1980. The prevalence of obesity in the United States of America (USA) is near 40% and its annual medical cost is around $200 billion. Management of obesity requires multidisciplinary approaches. Available options for weight reduction include diet, food supplement, exercise, behavior change, drug, medical device, gut microbiome manipulation, and surgery. In the USA, only 2% of subjects with obesity receive anti-obesity drugs. Properties and Mechanisms of Action: Anti-obesity medical devices represent a heterogenous family in terms of regulation, presentation, usage/administration, mechanism of action, effectiveness, safety, availability, and cost. Unlike anti-obesity drugs that act chemically through specific receptors, anti-obesity medical devices act rather mechanically. They do not have systemic absorption, specific metabolism, or receptors, and, therefore, have no side effects related to the impact on different organs through the bloodstream. Anti-obesity medical devices can cause weight loss through different mechanisms. They can cause a decrease in food intake at the level of oral cavity (by limiting the bite size) or stomach (by reducing the available stomach volume), or can cause a decrease in the amount of available/absorbed nutrient at the level of stomach (by removing part of the gastric contents) or intestine (by bypassing part of the intestine). In the USA, the Center for Devices and Radiological Health (CDRH) of the Food and Drug Administration is approving/clearing the anti-obesity medical devices. Based on the expected weight loss, CDRH categorizes medical devices as weight-loss devices (“more” weight loss) or weight-management devices (“less” weight loss). The weight-loss devices include gastric band devices, gastric space-occupying devices, and gastric emptying devices. The weight-management devices include oral removable palatal space-occupying devices and ingested transient gastric space-occupying devices. Anti-obesity medical devices should be used in conjunction with healthy lifestyle including diet and exercise. The degree of weight loss, the side effects, and the cost of anti-obesity medical devices vary considerably by the type of medical device. Conclusion: Anti-obesity medical devices are an option for subjects who have not responded to more conservative treatments (lifestyle, drugs) but who want an alternative to more aggressive interventions (bariatric surgery). Given the large market size of obesity treatment and the current level of undertreatment with anti-obesity drugs, anti-obesity medical devices can play a major role in the management of obesity.
SUN-LB76 Euthyroid Ophthalmopathy in Coexistence With Differential Thyroid Carcinoma
Authors: Garate Dioni , Villarreal Adriana , Alfaro Gisella , Salsavilca Elizabeth , Chiu Erika 
Published: May 2020

Abstract
Introduction: Thyroid ophthalmopathy (TAO) is a rare autoimmune disorder in euthyroid patients; less frequent in those with negative autoantibodies and thyroid cancer. TSH-R stimulating antibodies bind to said receptor in orbital fibroblasts, producing the secretion of cytokines, hyaluronic acid and adipogenesis that contribute to TAO1. Clinical case: 54-year-old woman has had orbital alterations compatible with TAO for four years, CAS score 2/7-Eugogo Mild, studies of thyroid function and TSI/AbTPO/AbTg antibodies in normal ranges; therefore, she received oral corticotherapy and subtenonial corticosteroid injections. She was subsequently evaluated in Endocrinology, where goiter was found. Thyroid ultrasound showed hypoechogenic left thyroid nodule (14 mm), FNA: Bethesda VI and Pathological anatomy: Papillary thyroid carcinoma. She received ablative therapy with I-131 (30 mCi). Currently with excellent response. During follow-up, ophthalmologic evaluation showed: CAS score 0/10 and VISA score 0/10. Presents palpebral retraction, corneal erosions and PIO elevation. In Tomography: increase in volume of the lacrimal glands and extraocular muscles predominantly in the upper and medial rectum, as well as a thickening of the upper eyelid lift muscle, with greater involvement in the left orbit. These findings are compatible with inactive TAO with an expansive “white eye” phenotype, generally with a lower risk of compressive neuropathy.Discussion: In addition to normal thyroid function and mild TAO, the patient has the characteristic of presenting negative antibodies. Associated with TSH-R, factors such as IGF-1 can be found in the pathogenesis of TAO, which can generate a similar effect1. Likewise, IGF-1 stimulates cell proliferation, and is related to neoplasms such as thyroid carcinoma2. Conclusions Differentiated thyroid carcinoma should be ruled out in all patients with TAO, whether euthyroid or not. Studies confirming the relationship of IGF-1, TAO and thyroid carcinoma are necessary. References: 1. Yu et al. Thyroid-associated orbitopathy in patients with thyroid carcinoma A case report of 5 case. Medicine (2017) 2. Manzella et al Activation of the IGF Axis in Thyroid Cancer: Implications for Tumorigenesis and Treatment. International Journal of Molecular Sciences, (2019). 20 (13), 3258.
SAT-LB54 Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy
Authors: Tumyan Gayane , Mantha Yogamaya , Gill Rahul , Feldman Mark 
Published: May 2020

Abstract
Background: Pituitary apoplexy (PA) is a rare endocrinopathy that requires prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon.
Clinical Case: A 67-year-old man presented to our hospital with a 2-week history of worsening bilateral frontal headache, nausea, and dry heaving. On admission, the patient was somnolent with a score of 13 on the GCS assessment (E2, V5, M6). The neurological exam was overall normal with normal ocular motion and intact cranial nerves, except for a left eye peripheral vision defect. Plain head CT revealed a well-circumscribed ovoid pituitary mass with suprasellar enlargement, consistent with a pituitary macroadenoma. Sellar MRI showed a pituitary mass, roughly 20 x 19 x 24 mm, bulging into the suprasellar cistern with optic chiasm elevation. Analysis of pituitary function revealed low ACTH concentration of 2.8 pg/mL (n = 7.2 - 63.3 pg/mL), a low random cortisol level of 1.7 ug/dL (n = 2.9 - 19.4 ug/dL), a low TSH of &lt; 0.1 uIU/mL (n = 0.35 - 4.9 uIU/mL), a low free T4 level of 0.72 ng/dL (n = 0.77 - 1.48 ng/dL), a low LH of 0.8 IU/L (n = 1.7 - 8.6 IU/L) with a very low total testosterone level of &lt; 3 ng/dL (n = 300 - 720 ng/dL) and normal prolactin, IGF-1 and GH levels. On hospital day 2, the patient had worsening encephalopathy with left eye ptosis and decreased vision. Repeat CT and MRI showed no interval change in the pituitary adenoma or evidence of bleeding. An immediate lumbar puncture was performed and CSF analysis revealed an increased leukocyte count of (1106/mm3) with 89% neutrophilic granulocytes, and increased total protein level of 138 mg/dL (n = 15 - 40 mg/dL), red blood cell count of 2040 without xanthochromia and glucose of 130 mg/dL (n = 40 - 70 mg/dL). Based on the laboratory results and new symptoms, empirical antibiotic (vancomycin, ceftriaxone, and ampicillin) therapy was started for suspected bacterial meningitis before the confirmation of the CSF culture study. CSF culture did not grow any organisms. Given the sudden visual impairment and neurological deterioration, the patient underwent transsphenoidal resection of the tumor with free nasal mucosal graft reconstruction. Histological examination revealed a necrotic pituitary adenoma with apoplexy and no evidence of hemorrhage. Postoperatively, his neurological exam greatly improved. His left pupil was reactive to light and the third palsy was improving.
Conclusion: This case reinforces the importance of including PA in the differential diagnosis of acute headache, particularly in patients presenting with visual disturbances. Patients with PA often present with sterile meningitis due to increased debris and blood in the subarachnoid space which closely mimics acute bacterial meningitis. While MRI remains a sensitive imaging modality for the detection of PA, the latter remains a clinical diagnosis. Timely diagnosis with high clinical suspicion and treatment is essential.
SUN-LB37 Atypical Presentation of Primary Adrenal Angiosarcoma With Cushing’s Syndrome - a Case Report
Authors: Cardona Zulma , Haider Yasser A , Eisenberg Yuval 
Published: May 2020

Abstract
Angiosarcoma is a rare aggressive malignancy originating from the endothelium of blood and lymphatic vessels, accounting for 1% of all tissue sarcomas. These tumors usually invade skin and soft tissue, however they may also invade visceral organs and bones as metastatic disease. Approximately 50 cases have been reported in the literature describing primary adrenal angiosarcomas (PAA). This case represents the first report to describe concomitant Cushing’s syndrome in the setting of epithelioid PAA. A 38-year-old female with pre-diabetes mellitus and hyperlipidemia presented to the emergency department complaining of cough with bloody sputum. Physical exam was remarkable for bilateral lower extremity edema; no Cushing’s features appreciated. Bilateral subsegmental and lobar pulmonary emboli (PE) along with lytic lesions on the ribs were found on Computed Tomography (CT) PE protocol. Chest CT Angiography to prepare for arterial embolization to treat hemoptysis, demonstrated a large heterogeneous enhancing mass arising from the adrenal gland. MRI with adrenal protocol to evaluate incidentaloma revealed an indeterminate 5.2 x 5.6 x 5.2 cm right adrenal mass with central necrosis.Biochemical evaluation revealed a nonsupressible 1mg dexamethasone suppression test (3.3 ug/dL, ref: &lt;1.8 ug/dL), slightly elevated urine metanephrines (191 ug/d, ref: 39 -143 ug/d) and normal plasma metanephrines (0.16 nmol/L, ref: 0.0 - 0.49 nmol/L). Given the biochemical evidence of mild hypercortisolism and uncertainty of etiology of other CT findings, the decision was made to pursue adrenalectomy to aid in the presumed oncologic diagnosis. She underwent successful adrenalectomy, however the postoperative course was complicated by hypotension resistant to fluids. ACTH stimulation test revealed a baseline cortisol &lt;1.0 (ref: 0.0-9.0 ug/dL) with an ACTH of 8 pg/mL (ref: 6 to 58pg/mL), and 60 minute post stimulation cortisol level was 5.5 ug/dL (ref: &gt;18.0 ug/dL). She was started on hydrocortisone replacement therapy, with clinical improvement in hypotension and was eventually tapered off steroids completely.Surgical pathology identified positive staining for CD31, CD34, factor 8, CAM 5.2, and Vimentin consistent with epithelioid angiosarcoma with lymphovascular invasion. There was additionally evidence of adrenocortical hyperplasia on the tissue resected. She established care with oncology and is currently completing 8 cycles of paclitaxel for metastatic disease to bones and lungs. Our patient’s pathology results, and postoperative course suggest the presence of concomitant non-ACTH dependent Cushing’s syndrome associated with epithelioid PAA. This case highlights the importance of thorough biochemical testing before adrenalectomy in the setting of PAA given the possibility of Cushing’s syndrome, which could contribute to post-surgical complications, and prolonged hospital stays.
SUN-LB38 Adrenal Tumor Causing Unexplained Hyperhidrosis in a Young Man
Authors: Unterborn Rebecca , Bhatt Bankim 
Published: May 2020

Abstract
Introduction: Pheochromocytoma is a rare neuroendocrine tumor, afflicting around 0.8 out of 100,000 people per year [1]. The “classic triad” of headache, diaphoresis, and tachycardia is well documented in the literature. The “classic triad” in combination with hypertension has up to 91% sensitivity and 93.5% specificity for the diagnosis of pheochromocytoma [2]. Generalized sweating is part of the “classic triad”, however there is paucity of evidence in the literature describing diaphoresis as the only presenting symptom of pheochromocytoma.Case description: A 20-year-old male presented with five year history of worsening hyperhidrosis without any other associated symptoms. Vital signs were blood pressure of 138/82 mmHg and heart rate of 60 bpm. The remainder of the physical exam was normal. Laboratory testing showed 24 hour urine norepinephrine level of 1,002 ug/24 hours (normal: 0-135 ug/24hrs), plasma normetanephrine was 2,873 pg/mL (normal: 0-145 pg/mL) and plasma norepinephrine was 2,869 pg/mL (normal: 0-874 pg/mL). CT abdomen revealed a 4.0 x 3.1 x 4.3 cm left adrenal mass. After appropriate preoperative preparation, he successfully underwent a laparoscopic left adrenalectomy with complete resolution of diaphoresis. Pathology confirmed a completely resected pheochromocytoma.Discussion: This case reflects an atypical presentation of pheochromocytoma; a disease with high cardiovascular morbidity and mortality [3, 4]. The case demonstrates that the absence of hypertension or all three symptoms of the “classic triad” does not exclude the diagnosis of pheochromocytoma and any singular symptom of catecholamine excess warrants an evaluation for pheochromocytoma. This case report helps to establish the need to better quantify individual symptoms of patients with this disease in order to better understand the entire spectrum. Providers need to be aware of atypical presentation of this disease in order to decrease poor outcomes that can result from undiagnosed pheochromocytoma. 1. Beard, C.M., Sheps, S.G., Kurland, L.T., Carney, J.A., Lie, J.T., Occurence of pheochromocytoma in Rochester, Minnesota 1950-1979. Mayo Clinic proceedings, 1983.2. Bravo, E.L., Pheochromocytoma: New concepts and future trends. Kidney International, 1991. 40.3. Lenders, J.W.M., Duh, Q.Y., Young, W.F, et. al, Journal of Clinical Endocrinology and Metabolism. 2014.4. Zelinka, T., Petrak, O., Turkova, H., et. al, High Incidence of Cardiovascular Complications in Pheochromocytoma. Hormone and Metabolic Research, 2012.
SAT-LB3 Developing an Integrative Medicine Patient Care Protocol for Natural Fertility in Primary Infertile Couples: A Case Series
Authors: Hatzidakis Vassilia E 
Published: May 2020

Abstract
Background:Although advances in the field of Assisted Reproduction have improved significantly the reproductive outcome for infertile couples, success rates nonetheless remain low. Furthermore, several infertile couples are skeptical of using experimental or even established ART treatments, resulting in the need for reproductive health professionals to discuss other models which might best benefit patients who need fertility care.Clinical case series:All patients that were referred to our clinic for primary infertility (no positive pregnancy test after at least 2 years of unprotected intercourse) and had been either offered to proceed with IVF or had already a history of at least 1 failed IVF cycle, in the course of 1 year (March 2018-February 2019) were included in this study. All patients were younger than 42 years of age, AMH less than 1 ng/mL, FSH less than 12 IU/L (follicular phase FSH normal range 2.8-9.3 IU/L) and normal ovulation was present. Couples were counseled regarding a novel integrative model of achieving spontaneous pregnancy through expectant management while modifying key parameters affecting female fertility, developed after evidence-based appraisal of all relative literature. All 14 patients were examined for insulin resistance, subclinical thyroid disease, thrombophilia, and chronic endometritis and were offered the appropriate treatment, aiming for optimal (as opposed to within normal range) figures. For chronic endometritis both spouses received a one-month long triple antibiotic treatment. All patients were given careful personalized nutritional and vitamin supplementation guidelines. Regarding the psychological component of fertility all patients underwent monthly homeopathy and/or weekly acupuncture courses. All patients were designed to be followed-up for 6 months after completion of treatment (9 months after antibiotic treatment). 3 patients dropped out before receiving full treatment (rate 21%). 2 patients did not have a positive pregnancy test. All 9 remaining patients came back with a positive pregnancy test (rate 81% of those who completed treatment) on the first month of follow-up that resulted in an uncomplicated pregnancy and delivery of healthy singleton babies. Conclusion:This is the first case series indicating that expectant management could be the answer to some cases of infertility. Poor responders are sometimes reluctant to be involved in the global trend of IVF and ART, therefore a more holistic integrative approach might balance the imbalances and increase their fecundity. However, no causal inferences should be made from this consecutive case series regarding the efficacy of the investigated treatment.