bluuebunny/crossref_metadata_2025_split huggingface dataset:
SAT-571 Rare Case of Tocilizumab-Induced Severe Hypertriglyceridemia
Authors: Modi Ankur , Scholz Beth , Wenkert David 
Published: May 2020

Abstract
Tocilizumab (TCZ) is a monoclonal antibody against the IL-6receptor used in the treatment of rheumatoid arthritis (RA). Hypertriglyceridemia is a rare side effect of TCZ, occurring in&lt;1% of cases (1).
A 37 year-old woman presented with abdominal pain, nausea and diarrhea. Her past medical history included RA and dyslipidemia; she had no history of diabetes, hypothyroidism, renal disease, alcoholism or recent medication changes. Following failure of other immunosuppressant agents, IV TCZ was initiated. After two and a half years, TCZ formulation was changed to subcutaneous injections for convenience about 6 weeks prior to presentation. Family history included mother with dyslipidemia. Her vital signs were normal on admission with labs remarkable for lipase of 332 and triglycerides (TG) of 5680. Her TG 2months prior to initiating subcutaneous tocilizumab therapy was 1373. CT abdomen demonstrated findings of acute pancreatitis (AP). She was subsequently admitted to the ICU and started on an insulin drip, fibrate, statin and fish oil along with supportive care. TCZ was held. Because her TGs remained severely elevated, she was transferred to our facility for plasmapheresis with subsequent improvement of the same to 768 after two treatments.
TCZ was considered the probable etiology of her hypertriglyceridemia with subsequent AP after ruling out other secondary causes. Hereditary hypertriglyceridemia, given her family history, likely contributed to her chronically elevated TG’s.
TCZ has been reported to increase TG levels mainly through an increase in VLDL-TG content. TCZ was found to reduce hepatic LDLr expression thus reducing hepatic clearance of TGs and LPL mediated lipolysis of TG-rich lipoproteins (2). Despite the association of TCZ with increased lipid levels, it has a favorable impact on lipid metabolism via improved functionality of HDL-C and no impact in the atherogenic index; patients also experience a favorable response to statin treatment (3). In observational studies, TCZ shows a favorable effect on myocardial infarction compared to other biologic agents for RA, attributed partly to a decrease in lipoprotein(a) levels. Nonetheless, it should be used in caution in those with high cardiovascular risk, especially dyslipidemia (4).
1. Flaig T, Douros A. Tocilizumab-induced pancreatitis:case report and review of data from the FDA Adverse Event Reporting System. Journal of Clinical Pharmacy and Therapeutics 2016,
41:718-721.
2. Strang A, Bisoendial R. Atherosclerosis 229(2013):174-181.
3. Garcıa-Gomez C, Martın-Martınez M. Lipoprotein(a) concentrations in rheumatoid arthritis on biologic therapy:Results from the CARdiovascular inrheuMAtology study project. Journal of Clinical Lipidology (2017) 11:749-756.
4. CastagnéB, Viprey M. Cardiovascular safety of tocilizumab: A systematic review and network meta-analysis. PLoS ONE 14(8):e0220178.
SUN-388 Role of QUS and Functional Tests in Evaluating Fracture Risk Based on Frax Tool
Authors: Gama Eduardo Medeiros Ferreira , de Pinho Leandro Kasuki Jomori , Madeira Miguel , Duarte Carlos , Pessoa Girlene Canhete , Moraes Aline Barbosa , Amaral Maria Caroline Alves Coelho , Neto Francisco Paula Paranhos , de Farias Maria Lucia Fleiuss 
Published: May 2020

Abstract
Background: Osteoporosis is common among elderly people, and identifying those at high risk for fracture is very important.
Aim: To evaluate whether the use of quantitative calcaneal ultrasound (QUS), the Sitting–rising test (SRT) and handgrip test (HT) are additional tools for tracking fragility fracture risk when compared to FRAX and NOGG.
Methods: During the national campaign against osteoporosis, held in 2018 in Rio de Janeiro, participants were randomly selected to perform QUS, SRT and HT, besides categorization of the risk of major and hip fractures by FRAX and NOGG. The following adequacy values ​​were used: QUS T-score&gt; -1.05 (adequate) or ≤ -1.05 (inadequate);
Sitting – rising test (SRT) (composite score): age-reference values at quartiles 3 and 4 (adequate); quartiles 1 and 2 (inadequate); best result 3 attempts of the dominant arm handgrip test, according to age and gender: percentile ≥50 (adequate) and &lt;50 (inadequate); FRAX tool: suggests high risk for major osteoporotic fractures if &gt; 20% and for hip fractures when &gt; 3%; NOGG (complement to FRAX): patient′s risk for major and for hip fractures considered as low (green zone), medium (yellow zone) or high (red zone). Qui square test was used for associations.
Results: We included 162 individuals: 118 females, mean age 66.8 years and 44 males, mean age 71.8 years. High risk of hip fractures by FRAX was observed in 51% of those patients with a QUS T-score ≤-1.05 while it was observed in 28% of those with a QUS T-score&gt; -1.05 (p=0.005). An inadequate QUS T-score was also associated with a higher risk of hip fracture by NOGG (p=0.007). An inadequate SRT and HT were not associated with a high fracture risk.
Conclusions: As densitometry, a method established in clinical practice for the diagnosis of osteoporosis, has limitations in its use, other tools are necessary for tracking the risk of fragility fractures in these events. Quantitative calcaneal ultrasound was a good predictor of hip fracture risk, while SRT and HT were not capable of evaluate for fracture risk stratification in our study, reinforcing the need for QUS for screening in large populations. Having strength and functional ability did not eliminate the need for investigation.
SAT-443 Impact of Fasting on Plasma Thyrotropin in Hypothyroid Patients Taking Levothyroxine During Ramadan (IFT-R Study)
Authors: El-Kaissi Samer , AbdelWareth Laila , Dajani Ruba , St John Terrence Lee , Santarina Sherry Ann , Makia Fiona , AlTakruri Malak , Kaskas AbedElRahman , Ahmed Yahya 
Published: May 2020

Abstract
Background and Aim: We previously showed in a retrospective analysis that the plasma TSH rises significantly post-Ramadan in levothyroxine-treated hypothyroid patients, possibly as a result of changes in the eating habit during the non-fasting period from dusk until dawn. The aim of this study is to determine the best time for taking levothyroxine during Ramadan in order to minimize changes in thyroid function tests.
Methods: in a randomized prospective design, hypothyroid patients taking levothyroxine for greater than 6-months were randomized to take levothyroxine at one of the following 3 times during Ramadan: (group 1) at dusk after a prolonged fast and 30-minutes before the Iftar meal, (group 2) ≥ 3-hours after the Iftar meal, or (group 3) at dawn 30-minutes before Suhur meal. Patients were instructed to allow a minimum of 3-hours between the last meal and levothyroxine and to refrain from eating and drinking for at least 30-minutes after taking levothyroxine. Thyroid function tests were performed within 3-months before Ramadan and within 6-weeks post Ramadan. To estimate intent-to-treat effects, we examined pre- and post-Ramadan thyroid function tests in relation to the assigned levothyroxine administration times.
Results: 147 patients were randomized into the study and the respective number of patients in groups 1, 2 and 3 were 50, 46 and 51. The mean age of participants was 43.5±12.4 years [range 21.0-86.0] and 78% were females with no statistical differences in the mean age or gender distribution between the 3 groups. The respective pre-Ramadan mean TSH values for the 3 groups were 2.49 mIU/L, 2.16 mIU/L and 3.37 mIU/L with no significant differences at baseline. Post-Ramadan mean TSH values were 2.47 mIU/L, 4.26 mIU/L and 3.85 mIU/L for groups 1, 2 and 3 respectively. The pre- and post-Ramadan mean TSH differences were significant only for group 2, who took levothyroxine 3-hours post-Iftar (P-value 0.041). There were no significant differences in the free-T4 levels across the 3-groups before and after Ramadan. In a subset of 85 patients, the preferred times for levothyroxine administration during Ramadan were 44.7% before Iftar, 50.6% post-Iftar and only 4.7% were in favor of taking the medication before Suhur meal.
Conclusions: Levothyroxine-treated hypothyroid patients who took levothyroxine 3-hours after the main Iftar meal showed a significant increase in plasma TSH post-Ramadan, possibly reflecting a reduced time period between levothyroxine administration and the previous meal. There was no significant change in the mean plasma TSH for patients taking levothyroxine at dusk before Iftar or at dawn before Suhur. The least patient-preferred time for taking levothyroxine was at dawn before Suhur possibly due to time constraints before the start of fasting.
SAT-630 Nutritional Influences on One Carbon Metabolism Exacerbate Diabetic Cardiomyopathy and Nephropathy
Authors: Al-Humadi Ahmed W , Strilakou Athina , Al-Humadi Hussam W , Al-Saigh Rafal , Liapi Charis 
Published: May 2020

Abstract
Choline (Ch) exerts a key role as methyl donor in the one carbon pathway and is an essential nutrient for the optimal development and function of a number of biological systems including the cardiovascular and urinary system. Ch-deprivation has been associated with heart function impairment, insulin resistance, abnormal fat metabolism and acute kidney injury. Diabetes mellitus is a common metabolic disorder with increased prevalence in aging and diabetic patients are of higher risk to develop heart and kidney failure. This study aims to investigate the impact of dietary Ch-deprivation on cardiac and renal function in a streptozotocin (STZ) experimentally induced diabetic setting. Twenty-four male adult Wistar rats, were randomly separated into four groups: control, choline deficient through choline deficient diet (CD), STZ induced diabetic (DM) and diabetic-choline deficient (DM+CD) group. After 5 weeks of dietary intervention, echocardiographic measurements, myocardium and kidney histological examination along with Vascular Endothelial Growth Factor-A (VEGF-A165) and Kidney Injury Molecule-1 (KIM-1) immunohistochemistry expression were performed. DM+CD rats demonstrated an exacerbation of myocardial inflammation and fibrosis accompanied by preserved ejection fraction but with an increased left ventricular (LV) wall tension index and velocity and a decreased LV posterior wall thickness compared to DM group. VEGF-A165 expression both in heart and kidneys was abruptly upregulated in the CD rats with a downward trend under the diabetes mellitus entity reaching significant downregulation in the renal tissue. KIM-1 expression was significantly increased under the insult of both choline deficiency and diabetes mellitus depicting a possible synergistic, though detrimental, effect compared to each condition alone.
In conclusion, five weeks of dietary choline deprivation aggravates the inflammation and fibrosis in the heart and kidneys of diabetic rats leading to organ dysfunction. The structural impairment of the choline deprived diabetic heart with evidence of stiffness and dilation of the left ventricular cavity with preserved systolic function indicates the emergence of a new distinct phenotype of cardiomyopathy that combines features of the restrictive and dilated type at the same time. Moreover, in this setting the kidney injury gets worse implying that diabetic nephropathy might establish earlier and accelerate more quickly in choline deficiency conditions.
SAT-623 Glucose Intolerance Modifies the Association Between Insulin-Like Growth Factor-1 and All-Cause Mortality
Authors: Visaria Aayush , Dharamdasani Tina 
Published: May 2020

Abstract
Background: Despite an increase in literature on insulin-like growth factor-1 (IGF-1) and its impact on insulin sensitivity, there remains controversy over its association with all-cause mortality. Insulin interacts with IGF-1 and its binding proteins, forming a growth hormone/IGF-1/insulin axis that may be impaired in Type II diabetes and/or prediabetes. We hypothesized that the association between insulin and IGF-1 with all-cause mortality differs in those with glucose intolerance (GI) in a nationally representative U.S. population with long-term follow-up. Methods: A total of 5,283 non-pregnant adults &gt;20 years from the National Health and Nutrition Examination Survey (NHANES)-III (1988-1994) were linked to the National Death Index through 2015. Glucose intolerance was classified as per fasting blood sugar (≥100 mg/dl), hemoglobin A1c (≥5.7%), medication use, or self-reported diagnosis. IGF-1 was categorized into sex-specific quartiles. To analyze the joint impact of insulin and IGF-1, we also categorized participants into four groups: Group I) IGF-1 &lt;230 ng/mL & insulin ≥11 uIU/mL, II) IGF-1 &lt;230 & insulin &lt;11, III) IGF-1 ≥230 & insulin ≥11, and IV) IGF-1 ≥230 & insulin &lt;11. Our primary outcome was all-cause mortality. We used survey design-adjusted Cox regression to estimate the risk of all-cause mortality, adjusting for confounders. Results: Among the 5,283 subjects, 2,214 (42%) had GI. Participants had a mean follow-up of 22.1 years, during which 1,835 (34%) of them died. Those with GI in the highest quartile of IGF-1 had an unadjusted 64% lower risk of all-cause mortality compared to the lowest quartile (GI = unadjusted OR [95% CI]: 0.37 [0.24,0.55]). This association, although protective, was significantly less protective than those with normal glucose tolerance (NGT) (unadjusted OR: 0.16 [0.12,0.23]). After adjusting for confounders, these associations became insignificant (GI = aOR: 1.02 [0.73,1.42], NGT = aOR: 1.04 [0.74,1.46]). When estimating risk of mortality among joint groups of insulin and IGF-1 levels, those in Group I with NGT had 20% increased adjusted odds of mortality (1.30 [1.01,1.71]), while in GI subjects, there was an insignificant increased odds of mortality (1.17 [0.84, 1.62]). Neither subgroup in Group 2 had significant adjusted odds of mortality relative to Group 4. Group 3 subjects with GI had an adjusted, insignificant 24% increased odds of mortality (1.24 [0.91, 1.70]) compared to 70% increased odds in NGT subjects (1.69 [1.18, 2.42]). Conclusion: The differences in odds of all-cause mortality across IGF-1 quartiles in glucose tolerant vs. intolerant individuals suggests that IGF-1 may play less of a protective role in Type II diabetes and prediabetes. Among those with normal glucose, higher insulin levels, regardless of IGF-1 levels, was associated with all-cause mortality. This association did not hold in those with glucose intolerance.
SAT-194 Pheochromocytoma During Pregnancy: A Ticking Time Bomb
Authors: Sarmiento-Ramon Juan Camilo , Sosa-Pagan Max , Dendy Jared 
Published: May 2020

Abstract
Background: A pheochromocytoma diagnosed during pregnancy is an extremely rare condition with an incidence of 0.002% of all pregnancies. If untreated, consequences are devastating including a maternal and fetal mortality as high as 50%. There is no consensus in the literature regarding the management of this condition during pregnancy.
Clinical Case: A 25-year-old woman G4P1021 presented at 15 weeks of gestation with shortness of breath, palpitations and chest pain. Vitals revealed hypertension and tachycardia. A CT angiogram of the chest was obtained which ruled out a pulmonary embolism but detected a 5.5-cm left adrenal mass. Biochemical work up revealed elevated plasma and urine normetanephrines. A dexamethasone suppression test was normal. A plasma aldosterone to renin ratio was normal. An MRI of the abdomen confirmed the presence of a large heterogeneous 6-cm left adrenal mass. A multi-disciplinary team discussion including an obstetrician, endocrinologist, endocrine surgeon and anesthesiologist led to the decision to perform an adrenalectomy during the second trimester. Doxazosin was started at a dose of 2 mg daily, which was later titrated up to 2 mg BID with excellent blood pressure control. Metoprolol was added 4 days prior to surgery for heart rate control. A laparoscopic left adrenalectomy was performed at 19 weeks of gestation. Intra-operatively, the patient had a brief period of hypotension which resolved with IV fluids and a short course of vasopressors. Patient did not have any post-operative complications and is currently normotensive and with a normal heart rate without the use of any anti-hypertensive medications. Repeat plasma metanephrines and normetanephrines were within the reference range. Her latest obstetric ultrasound at 20 weeks of gestation revealed a live fetus without anatomical abnormalities. The fetus is within the normal weight and size percentiles.
Conclusion: A pheochromocytoma is a rare event during pregnancy and is associated with high maternal and fetal mortality rates. Timely diagnosis and proper treatment are of utmost importance to reduce mortality. The optimal time for surgical tumor removal has not been established but the second trimester appears to be safest period given the risk for spontaneous abortion during the first trimester and that the enlarged uterus diminishes tumor accessibility during the third trimester. Pre-operative medical management is crucial similar to non-pregnant patients. The treatment of these patients should include a dedicated team including an obstetrician, anesthesiologist, surgeon and endocrinologist.
SUN-491 A Diagnosis of Thyroid Cancer Reveals a Triple Threat
Authors: Dengler Samuel Lee , Reid Lisa , Klump William , Shersher David , Squillante Christian , Ferber Andre , Morgan Farah Hena 
Published: May 2020

Abstract
Introduction: The risk of secondary malignancies is increased in patients with papillary thyroid cancer (PTC). It is not completely clear if this risk is due to radioactive iodine treatment or due to other causes. We present a case of a patient diagnosed with papillary thyroid cancer (PTC) found to have lung cancer and small lymphocytic lymphoma which appear to be unrelated to radioactive iodine treatment.
Case Presentation: A 72 yo woman with a history of Graves’ disease, atrial fibrillation, and hyperparathyroidism initially presented to care for weight loss. She was found to have hyperthyroidism and was treated with methimazole. Thyroid ultrasound revealed multiple nodules including a 17mm right lower pole nodule with irregular borders for which she underwent FNA. Pathology demonstrated atypical-cells of undetermined significance (AUS), but thyroseq revealed a BRAF V600E mutation. She underwent total thyroidectomy with pathology showing multifocal thyroid cancer, 12mm and 0.8mm with 3/11 involved lymph nodes and right parathyroid adenoma. Given a questionable lower left lung nodule on preop CXR, she underwent CT chest which revealed a 2cm lung nodule. She had video assisted thoracoscopic (VATS) left lower lobe wedge resection with completion left lower lobectomy for a 3 cm lung adenocarcinoma with negative margins and 33 negative lymph nodes. She was subsequently treated with RAI after recovery from VATS procedure. Pretreatment thyroglobulin was 0.8 ng/ml with negative thyroglobulin antibodies. One month after her RAI treatment, ultrasound of the neck revealed suspicious bilateral level IV lymph nodes which increased in size during short term follow up. Serum thyroglobulin was 0.3ng/ml with negative antibodies and TSH 0.29 mIU/L. Biopsy of right level IV lymph node was positive for PTC with thyroglobulin washout &gt;5000 while left level IV lymph node was negative for PTC and Tg washout was 0.1. She subsequently underwent right-sided modified radical neck dissection, with lymph nodes revealing PTC also involved by small lymphocytic lymphoma. She had repeat RAI ablation for thyroid cancer and is being actively monitored for her small lymphocytic lymphoma and lung adenocarcinoma.
Conclusion: We present a patient with no known history of malignancy who presented with 3 de novo primary malignancies. This case may demonstrate an increased risk of malignancy in patients with thyroid cancer not necessarily related to radioactive iodine treatment.
MON-909 Diabetic Ketoacidosis Following Treatment of Endogenous Hyperinsulinism
Authors: Murari Keerti , De Aguiar Renata Da Silva Belfort 
Published: May 2020

Abstract
Background: There has been only one case of Diabetic Ketoacidosis (DKA) reported following treatment of endogenous hyperinsulinism in a 16 month old.[1] This has not yet been described in adults.
Clinical Case: An 85 Y/O M with a PMH of metastatic gastric adenocarcinoma complicated by gastric outlet obstruction requiring TPN was admitted for symptomatic hypoglycemia. On the day of admission, his wife noted that he appeared confused and checked his capillary blood glucose, which was 35, prompting her to call EMS who gave him IV dextrose 50% (D50).
In the ED, he was placed on continuous dextrose 10% (D10) due to persistent hypoglycemia. To investigate the cause of hypoglycemia, D10 was stopped and a fast test was initiated. The patient developed symptomatic hypoglycemia 9 hours after stopping the D10. Laboratory results showed: plasma glucose 43 mg/dL, c-peptide 3.1 nmol/L, pro-insulin 18.7 pmol/L, insulin 10.7 uU/mL, beta-hydroxybutyrate (BHOB) 0.08 mmol/L. Insulin antibody and screen for oral hypoglycemic drugs were negative. Glucagon administration raised his blood glucose from 43 mg/dL to 50 mg/dL, 84 mg/dL, and 106 mg/dL after 10, 20, and 30 minutes, respectively. A diagnosis of endogeneous hyperinsulinism was made and the patient was started on Diazoxide 50 mg TID which was increased to 150 mg TID 2 days later. On day 3, Prednisone 20 mg daily was started due to inability to come off the D10 drip completely. On day 4 he was taken off D10. Due to plasma glucose &gt;150 mg/dL, prednisone dose was reduced to 10 mg and then 5 mg on day 5 and 6, respectively. On day 8, he was found to be in DKA with a plasma glucose of 250 mg/dL, metabolic acidosis with an anion gap of 20, HCO3 of 15 mg/dL, undetectable insulin levels and BHOB of 5.49 mmol/L. Prednisone and Diazoxide were discontinued and he was started on an intravenous insulin infusion. Within 24 hours he became persistently hypoglycemic requiring D50 and prednisone was restarted. DKA developed once again and the patient was subsequently made comfort measures only. Further investigation of his endogenous hyperinsulinism was not pursued. The patient was transferred to inpatient hospice, where he passed away several days later.
Conclusion: This is the first reported case of an adult patient with documented endogenous hyperinsulinism developing DKA following treatment with diazoxide and prednisone. Reference: (1) Mangla et al. J Ped End Met. 2018; 31(8): 943-945.