bluuebunny/crossref_metadata_2025_split huggingface dataset:
SUN-425 Indiscriminate Thyroid Function Testing on Acute Hospital Admissions Reveals a High Abnormality Rate Requiring Follow Up
Authors: McEvoy Robert P , O’Riordan Anthony , Hannon Mark J 
Published: May 2020

Abstract
The population attending the Medical Assessment Unit at our hospital comprises patients attending electively for investigation and acutely unwell patients presenting for unscheduled care. The standard panel of blood tests taken on arrival includes thyroid function tests (TFTs, i.e. TSH and free-T4), despite a recent review questioning the clinical utility of this practice [1]. We performed a retrospective audit to determine what proportion of our patients had abnormal thyroid function on presentation, and whether these abnormal test results were being followed up.
Using the iSoft Clinical Manager software, a list was generated of all patients who attended the hospital between January 2018 and June 2018 inclusive. For each attendance, we recorded the date, medical record number, patient age, gender, and TFT result. Abnormal TFT results were classified as overt or subclinical hyper- or hypothyroid, or non-thyroid illness syndrome (NTIS), based on their admission TSH and free-T4. We then examined the hospital and primary care records of patients with abnormal TFTs to determine if they had ongoing thyroid follow up post discharge.
In total, 2,298 patients attended over the 6-month study period. The mean patient age was 67.2 years, and 49% were female. Thyroid function tests were ordered on the day of attendance for 1,688 patients (73%). Of these, 181 results (11%) were abnormal: 20 overt hyperthyroid (11%), 72 subclinical hyperthyroid (40%), 12 overt hypothyroid (7%), 35 subclinical hypothyroid (19%), and 42 NTIS (23%). Twenty of these patients died within 3 months of the abnormal TFT result (4 overt hyperthyroid, 3 subclinical hyperthyroid, 3 overt hypothyroid, 6 subclinical hypothyroid, and 4 NTIS). Of the remaining 161 patients, 74 (46%) had not been followed up within 3 months (4 overt hyperthyroid, 34 subclinical hyperthyroid, 3 overt hypothyroid, 15 subclinical hypothyroid, and 18 NTIS).
The low percentage of abnormal TFTs (11%) in this audit is in keeping with similar studies where thyroid function testing was performed on unselected hospital populations [1]. Subclinical hyperthyroidism was by far the most common abnormality found. A high percentage of abnormal tests (46%) were not followed up, with poor compliance with thyroid management guidelines [2]. Future work will investigate adoption of an ‘opt-in’ order system [3] and electronic alerts to flag abnormal results for follow-up.
[1] Premawardhana LD. Thyroid testing in acutely ill patients may be an expensive distraction. Biochemia medica. 2017; 27(2): 300-307.
[2] Ross DS et al. 2016 American Thyroid Association Guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016 Oct; 26(10):1343-1421.
[3] Leis B et al. Altering standard admission order sets to promote clinical laboratory stewardship: a cohort quality improvement study. BMJ Qual Saf. 2019; 28(10): 846-52.
SAT-465 Steroid-Responsive Encephalopathy Associated with Autoimmune Thyroiditis: Diagnosis or Distraction?
Authors: de Souza Tamara Gizelle , Bustos Mario Andres , Kargi Atil Yilmaz 
Published: May 2020

Abstract
In 1966 a case of episodic encephalopathy with anti-thyroid antibody (ATAb) positive Hashimoto’s thyroiditis was first reported. Controversy persists regarding Hashimoto’s encephalopathy, now known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) and any relationship with ATAb. There is no literature supporting an etiologic role of ATAb in SREAT. Nor has there been correlation shown between ATAb titer and severity of thyroid dysfunction or SREAT(1).
A 56 yo female was admitted to a community hospital three times with visual hallucinations and slurred speech. Brain MRI, LP and standard tests including C3/C4, folate, B12, ANA and ANCA were unrevealing. Thyroglobulin antibodies (TgAb) and anti-thyroid peroxidase antibodies (TPOAb) were positive. Diagnosed with SREAT with relief of symptoms on high dose IV corticosteroids. Discharged on oral prednisone. Seven months later she began experiencing progressive proximal weakness of all extremities associated with exertional dyspnea, fatigue and weight gain. EMG studies indicated steroid-induced myopathy of the proximal extremities. After prednisone tapering, she was admitted to our institution with acute confusion, blurred vision, fever, tachycardia, tachypnea and hypoxemia.
Examination showed Cushingoid features. Labs showed hyperglycemia, ANA (+), TPOAb (+), TgAb (+), low FreeT4, low T3, normal TSH and elevated IgG in the CSF. Brain MRI showed meningeal enhancement of parieto-occipital lobes and left tentorium. Empiric antibiotics started to cover infectious meningoencephalitis. Endocrinology consulted for iatrogenic Cushing’s syndrome with hyperglycemia, abnormal thyroid function tests (TFTs) with positive ATAb and evaluation for SREAT. We recommended tapering steroids and evaluation for infectious, autoimmune or paraneoplastic causes of encephalopathy, before presuming SREAT. Rheumatological and infectious work-up was negative. CT chest showed nodular densities and CT abdomen showed hepatic, splenic and right inguinal region masses. Biopsy of inguinal mass showed Diffuse Large B-cell Lymphoma confirmed on bone marrow biopsy. CSF flow cytometry was unrevealing, likely due to prior steroids. Leptomeningeal enhancement likely reflected leptomeningeal metastases. Treated with systemic R-CHOP, high dose MTX, intrathecal MTX, cytarabine and corticosteroid tapering. Complete remission was achieved with normalization of TFTs, resolution of her Cushingoid and encephalopathic features.
This case illustrates SREAT as a diagnosis of exclusion. ATAbs may be positive in non-thyroid autoimmune disorders, other neurological conditions and 10-20% of the general population (2). B cell lymphoma with leptomeningeal metastasis caused encephalopathic features which improved with corticosteroids. Ascribing a diagnosis of SREAT led to delayed cancer diagnosis and treatment.
SAT-618 Nattokinase to Improve Insulin Sensitivity and Weight Loss in Women with Obesity +/- Diabetes
Authors: Cobos Leopoldo M , Torre Yanira Sanchez-De La , Herbst Karen L , Beltran Karen 
Published: May 2020

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

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

Abstract
Introduction: Thyroid cancer is the sixth most common type of cancer in the UAE. It has been observed that the incidence of thyroid cancer has been steadily increasing worldwide. However, limited studies about thyroid cancer has been reported from the Arab gulf region.
Objective: The objective of this study was to describe the clinical and surgical characteristics of patients with thyroid cancer in the UAE population.
Methods: Retrospective analysis was performed on all adult patients attending thyroid cancer clinic at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi, UAE over ten years from 2008 to 2018. All patients with a confirmed histological diagnosis of thyroid cancer who had surgical intervention with long-term follow up data on cancer outcome have been included. Categorical variable analysis and descriptive analysis were used to identify factors associated with increased risk of developing thyroid cancer.
Results: Total number of 203 patients with confirmed diagnosis of thyroid cancer were included. Most of the patients were female (72.9 %, n=148). Mean age at the time of diagnosis was 40±13 years. Papillary thyroid carcinoma was the most common thyroid cancer observed (95.6%, n=194) followed by follicular thyroid carcinoma (2%), medullary thyroid carcinoma (1.5%) and mixed medullary-papillary (0.9%). Classical variant and follicular variant of papillary thyroid carcinoma were the two most commonly observed histological subtypes of thyroid cancer with prevalence of 54.7 % and 21.7 % respectively. 91.1% (n=185) of patients had total thyroidectomy and 8.9%(n=18) had hemithyroidectomy. Female gender has been observed to be associated with higher prevalence of thyroid cancer (OR 2.78, 95% CI 1.18–4.50, p=0.001). Smoking status did not show any significant association with developing thyroid cancer. Recurrent thyroid cancer was observed in 9.4%(n=19). Most of recurrence happened as local metastasis 89.5%(n=17). The mean time of recurrence was 24 months (range, 7–64 months).
Conclusions: Our data demonstrate that in the UAE population, papillary thyroid cancer is the most common type of thyroid cancer. Female gender is observed to be associated with higher risk of thyroid cancer. Recurrence rate of thyroid cancer noted to be 9.4%. Further studies are required to investigate factors associated with recurrence and cancer free survival rates.
MON-916 Pure Large Cell Neuroendocrine Carcinoma (LCNEC) of the Gall Bladder in a Patient with Down Syndrome - a Rare Case of an Aggressive Tumor of the Gall Bladder
Authors: Azmath Misbah , Dunbar Ashley , Siddiqui Imran 
Published: May 2020

Abstract
Background: Pure large cell neuroendocrine carcinoma of the gall bladder (LCNEC-GB) is an extremely rare entity, with only 12 such cases reported in literature to date. None has been reported in a patient with genetic disorders. We describe the case of a patient with pure LCNEC-GB in the presence of Down syndrome and prior biliary atresia.
Case:
A 49-year-old female with Down Syndrome and history of neonatal surgery for congenital duodenal atresia presented with fever, vague abdominal discomfort and 6 month history of 15 pound weight loss. CT abdomen revealed a 5 X 4.2 cm exophytic, heterogeneously enhancing mass in the gall bladder fossa extending into segment 4B-5 of liver with mild intrahepatic biliary dilation, along with a 9 cm cystic lesion in continuity with the duodenum which was confirmed to a dilated duodenal anastomosis (from prior biliary surgery) on endoscopy. There was high suspicion for malignancy (gall bladder carcinoma versus intrahepatic cholangiocarcinoma) and subsequent metastatic workup including tumor markers, staging CT chest, MRI of the abdomen and diagnostic laparoscopy was negative.
The patient underwent robotic converted to open en bloc resection of the gallbladder mass with segment 4B-5 liver resection and adherent loops of small bowel as well as resection of the dilated duodenal anastomosis followed by reconstruction with a gastrojejunostomy and Roux-en-Y/small bowel entero-enterostomy and closure of duodenotomy.
Pathology demonstrated poorly differentiated “pure” large cell neuroendocrine carcinoma (G3), 6 cm in greatest dimension, with invasion of liver, duodenum and stomach, negative liver and gastric/small bowel margins. Lymphovascular invasion (LVI) was present with no perineural invasion (PNI), and 3/15 lymph nodes involved. Staging was determined to be pT4pN1.
Patient was considered for adjuvant chemotherapy based on few case reports (platinum/etoposide) but unfortunately developed systemic complaints of fevers, fatigue, pain in bones and joints 2 months post operatively. Workup revealed metastatic disease which was confirmed on biopsy. Several small satellite liver lesions were also identified which was consistent with metastatic hepatic disease. Patient and family elected to proceed with hospice. Patient died within 4 months of surgery.
Conclusion:
Pure LCNEC-GB is an extremely rare and aggressive tumor with a poor prognosis as seen in our patient. This is the first reported case of pure LCNEC-GB in a patient with a genetic syndrome, although it is unknown if it had any causal relationship with the tumor. Prior biliary atresia/post -surgical inflammation may have also contributed to its pathogenesis by plausible development of metaplasia and expression of neuroendocrine cells which are normally absent in the gall bladder. Our case might help shed some light into pathogenesis and genetic basis if any of this rare entity.
MON-678 Worsening Diabetes Control in Breast Cancer Patients Treated with Alpelisib
Authors: Geier Robert , Al Hommos Nisreen Abu , Nyenwe Ebenezer A , Eapen Anita 
Published: May 2020

Abstract
Introduction: A new phosphatidylinositol-3-kinase (PI3K) inhibitor, alpelisib (Piqray) has been recently approved for the treatment of breast cancer. Severe hyperglycemia has been reported as an adverse effect. Many breast cancer patients also have diabetes mellitus type 2 which puts them at a higher risk for this adverse effect.1 2
Case description: Patient is a 73 year old Caucasian woman with history of insulin treated type 2 diabetes mellitus and breast cancer who presented to the hospital with a left hip fracture. She has been recently started on alpelisib with worsening glycemic control. Glycemic control improved after alpelisib was held for 5 days. She resumed taking alpelisib and had an up titration of the insulin regimen. During her hospital stay, she suffered from hyperglycemia as high as 558 mg/dl. HbA1c increased to 11.3% from 6.5% reportedly before starting alpelisib. Patient was discharged on an intensified regimen with close follow up.
Discussion: Alpelisib is a PI3K inhibitor used in the treatment of postmenopausal women and men with hormone receptor positive, human epidermal growth factor receptor-2 negative, PIK3CA-mutated metastatic breast cancer. It inhibits PI3K which in turn inhibits protein kinase B (AKT). Insulin binds to insulin receptor substrates which activates PI3K, which in turn activates AKT resulting in translocation of the glucose transporter GLUT4 to the plasma membrane causing an uptake of glucose.3 A disruption in this pathway will result in hyperglycemia. Hyperglycemia was reported in 65% of patients with some cases found to be in ketoacidosis. This adverse effect means frequent monitoring of blood glucose is required following initiation of this treatment.4
Conclusion: Alpelisib is a new drug used in the select treatment of breast cancer. It can cause severe hyperglycemia and potential worsening of diabetes. Blood glucose should be monitored closely in patients with diabetes who are treated with alpelisib.
References:
Giovannucci E et al. Diabetes and Cancer. A consensus report. Diabetes Care 33:1674–1685, 2010.
Boyle P et al. Diabetes and breast cancer risk: a meta-analysis. British Journal of Cancer 107, 1608–1617, 2012.
Huang, X et al. The PI3K/AKT pathway in obesity and type 2 diabetes. International Journal of Biological Sciences14,1483–1496,2018.
Piqray [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp;2019
MON-290 Ipilimumab Immune-Related ACTH Deficiency Is of Acute Onset and Severe
Authors: Seejore Khyatisha , Giannoudi Marilena , Osborn Djoah , Lynch Julie Marie , Dunwoodie Elaine , Hook Jane , Marples Maria , Murray Robert Douglas 
Published: May 2020

Abstract
Introduction
Immune checkpoint inhibitors (ICIs) are immunomodulatory molecules that downregulate T-cell inhibiting-receptors or ligands to promote an enhanced anti-tumour response. Ipilimumab is a human monoclonal antibody directed against cytotoxic T-lymphocyte antigen-4 (CTLA-4) that has been shown to significantly improve survival in patients with metastatic melanoma. Immune-related adverse events (irAEs) occur in some patients with increased T-cell activation, of which ipilimumab-related hypophysitis (IH) is an important endocrine complication. The aim of this study is to determine the incidence of IH and characterise clinical presentation and outcomes in these patients.
Patients and Methods
We retrospectively evaluated consecutive adult patients with melanoma treated between December 2010 and August 2019 at a tertiary cancer centre. All patients received ipilimumab (3mg/kg) monotherapy or in combination with PD-1 (programmed cell death protein 1) inhibitors (nivolumab or pembrolizumab). Symptoms, pituitary hormone assessment, pituitary imaging and patient survival were assessed.
Results
Of 189 patients, 23 patients (12.2%, 13 male; age 59.2±11.8 years) presented with hypophysitis, two having received ipilimumab monotherapy. The median onset was at 17.3 weeks (range: 6.7-160 weeks) after treatment start, occurring in 57% after the fourth infusion (n=13). Five patients developed late-onset IH (range: 30.1-160 weeks) whilst on treatment with PD-1 inhibitors. Three of the patients developing hypophysitis (13%) received only a single ipilimumab infusion. Additional irAEs were diagnosed in 16 patients (70%) with IH, including six cases of destructive thyroiditis and one of autoimmune diabetes.
The main presenting symptom of IH was lethargy (n=18, 78%) followed by headache (n=8, 35%). Corticotroph deficiency with cortisol levels &lt;83 nmol/l (&lt;3μg/dL) at presentation were observed in all patients. At diagnosis, a drop in cortisol level of &gt;70% over a median time of 22 days (range: 3-39 days) was evident in 87% patients. A fall in fT4 level of at least 20% from baseline was observed in ten patients (59%, 10/17 – after excluding patients with thyroiditis) at a median of 4 weeks (range: 0-8 weeks) prior to the diagnosis of IH. Gonadotroph deficiency was detected in three male patients.
At the end of follow-up (median 14.3 months, range: 1-61.5 months after IH diagnosis), corticotroph deficiency was persistent in all patients; seven of ten patients recovered thyrotroph function and gonadotroph deficit resolved in one patient. Three patients with hypophysitis died within the first year of immunotherapy.
Conclusion
The incidence of IH was 12.2%, predominantly occurring after the fourth infusion. IH is characterised by acute severe drop in cortisol levels to less than 3μg/dL. A falling fT4 may herald development of ACTH deficiency.