bluuebunny/crossref_metadata_2025_split huggingface dataset:
SAT167 Risk Of Life Threatening Hypoglycemia When Using U-100 Insulin Syringes To Administer R U-500 Insulin
Authors: Rizwan Tehlil , Alchalabi Marwah , Arora Gunjan , Qureshi Ursula N , Qureshi Faisal 
Published: October 2023

Abstract
Disclosure: T. Rizwan: None. M. Alchalabi: None. G. Arora: None. U.N. Qureshi: None. F. Qureshi: None.
Background: Humulin R U-500 is a concentrated human insulin indicated to improve glycemic control in adults and children with diabetes mellitus requiring more than 200 units of insulin per day. R U-500 insulin is five times more concentrated than U-100 insulin. Clinical Case: A 42-Year-old woman with medical history of depression, hidradenitis, morbid obesity, hypertension, hyperlipidemia, chronic headache, and type 2 diabetes mellitus was on R U-500 insulin, Jardiance, and Victoza. Patient presented with low blood glucose levels. Patient reported that her home insulin regimen is 20 units of R U-500 insulin with meals. Her home glucose diary showed blood glucose levels as low as 30-50 mg/dL. Recent hemoglobin A1c was 6.5%. Of note, the patient was unaware of hypoglycemic symptoms. Upon taking detailed history, and discussing insulin injection technique, it was apparent that the patient was administering insulin correctly. Upon further inquiry, the patient reported not being aware of the specialized R U-500 syringe. Patient expressed unfamiliarity after being shown images of the correct R U-500 syringe. It became apparent that the patient was using a U-100 insulin syringe to draw from R U-500 insulin vial which means she was receiving an incorrect dosage. Filling the U-100 syringe to the 20-unit mark with R U-500 insulin will deliver 100 units of R U-500 insulin which puts the patient at risk of severe hypoglycemia. During hospital stay, U-500 R insulin, Victoza, and Jardiance were stopped, the patient was started on basal and bolus insulin regimen, and blood glucose levels were monitored with meals and at bedtime. Blood glucose levels improved to 140-180 mg/dL. Upon hospital discharge, the patient was encouraged to switch to R U-500 KwikPen as this will be more accurate and safe.
Conclusion: The U.S. Food and Drug Administration approved a dedicated syringe for the administration of Humulin R U-500 insulin, which is now the only device approved for use with U-500 insulin vial. Do not switch between types of syringes because it may increase the risk of dosing errors.
Presentation: Saturday, June 17, 2023
SAT435 The Quest Of Elevated Dhea-s: Is It A Tumor Or Is It Ashwagandha?
Authors: Patel Shivani , Aluko Oluwatomisin A , Gallagher Thomas 
Published: October 2023

Abstract
Disclosure: S. Patel: None. O.A. Aluko: None. T. Gallagher: None.
Introduction: Ashwagandha (Withania somnifera) is a popular Indian ayurvedic herb that is readily available over the counter in the United States. Ashwagandha is known to increase in testosterone and DHEA-s levels in men. We hereby report a case of a female who had elevated DHEA-s due to intake of Ashwagandha. Case Report: A 27 year old female with past medical history of vitamin D deficiency, anxiety, X linked heterozygous adrenoleukodystrophy presents to establish care with endocrinology with complaints of unintentional weight gain of about 25lbs, inability to lose weight with lifestyle modifications, dizziness, light headedness and occasional salt cravings. Medication history is significant for using ashwagandha 600mg twice daily, probiotic-10. Vitals were BP 102/70 mmHg, HR 108 beats/min, RR 18 breaths/min, SpO2 98%, BMI 31.28kg/m2. Laboratory evaluation showed AM cortisol of 21.6 ug/dL H (6.2-19.4 ug/dL), ACTH 6.2 pg/mL (7.2-63.3 pg/mL), DHEA-s &gt;1000 ug/dL H (84.8-378 ug/dL), TSH 1.39 IU/mL (0.45-4.5 IU/mL), free t4 2.39 ng/dL H (0.82-1.77 ng/dL), IGF-1 252 ng/mL (91-308 ng/mL), 1mg dexamethasone suppression test resulted AM cortisol of 1.5 ug/dL (6.2-19.4 ug/dL). Subsequently, further work up revealed 17 hydroxyprogesterone of 158 ng/dL (luteal phase 35-290 ng/dL), total testosterone 176 ng/dL H (13-71 ng/dL), free testosterone 1.8 pg/mL (0-4.2 pg/mL), androstenedione 113 ng/dL (41-262 ng/dL), LH 2.5 mIU/mL (follicular phase 2.0-12.6 mIU/mL), FSH, 3.6 mIU/mL (follicular phase3.5-12.5 mIU/mL). Patient underwent CT abdomen and pelvis with and without contrast which showed normal adrenal glands, prominent right ovary and US Pelvis was recommended. Pelvic ultrasound showed normal ovaries. MRI pelvis with and without contrast revealed 1cm right ovarian hemorrhagic cyst. Patient was subsequently asked to stop all over the counter supplement medications and a DHEA-s level was checked about 6 weeks and was markedly reduced to 435 ug/dL. TSH and free t4 improved to 0.789 IU/mL and free t4 1.43 ng/dL respectively. Conclusion: This case highlights that over the counter, readily available supplements that are marketed for reducing stress may cause remarkable alteration of natural physiology. Ashwagandha’s use in men have been known to cause elevations in DHEA-s in men and this case highlights that Ashwagandha’s use in women can also cause elevation in DHEA-s and how a simple intervention of eliminating Ashwagandha can improve DHEA-s levels
Presentation: Saturday, June 17, 2023
SAT445 Exposure To Perfluoroalkyl Substances At Preconception In Association With Metabolic Phenotype In Women From Singapore
Authors: Cohen Nathan J , Yao Meizhen , Midya Vishal , India-Aldana Sandra , Andra Syam S , Narasimhan Srinivasan , Meher Anil K , Arora Manish , Yen Chan Jerry Kok , Chan Shiao Yng , Kway Yeshe , Michael Navin , Sadanathan Suresh A , Eriksson Johan G , Sendhil Velan S , Hian Tan Kok , Oulhote Youssef , Huang Jonathan , Valvi Damaskini 
Published: October 2023

Abstract
Disclosure: N.J. Cohen: None. M. Yao: None. V. Midya: None. S. India-Aldana: None. S.S. Andra: None. S. Narasimhan: None. A.K. Meher: None. M. Arora: None. J.K. Chan: None. S.Y. Chan: None. Y. Kway: None. N. Michael: None. S.A. Sadanathan: None. J.G. Eriksson: None. S.S. Velan: None. T.K. Hian: None. Y. Oulhote: None. J. Huang: None. D. Valvi: None.
Background and Aim: Exposure to perfluoroalkyl substances (PFAS) may result in adverse metabolic health outcomes, but few studies have focused on preconception PFAS exposures and metabolic dysregulation which could impact pregnancy. We assessed cross-sectional and prospective associations between preconception PFAS concentrations and glucose regulation, insulin sensitivity, and magnetic resonance imaging (MRI) based adiposity measures in a Singaporean cohort of women who were actively attempting to conceive. Methods: Our analyses included 384 participants from the Singapore Preconception Study of Long-Term Maternal and Child Outcomes (S-PRESTO), from which 126 underwent abdominal MRI at preconception. 15 different PFAS in preconception plasma samples were measured, and metabolic measures were cross-sectionally assessed at preconception (waist-to-height ratio [WHtR], 2-hour oral glucose tolerance test [OGTT] indices, and MRI-based measures of abdominal adiposity and liver fat), and prospectively at 24-28 weeks of gestation (2-hour OGTT indices). We used linear regression models to assess associations between individual PFAS and metabolic phenotype at preconception and pregnancy. In addition, we used Bayesian weighted quantile sum (BWQS) regression to assess the joint associations of the PFAS mixture with study outcomes. Results: We observed negative associations between perfluorononanoic acid (PFNA) concentrations and visceral adipose tissue (VAT; log2-transformed) volume (β per doubling of PFNA=-0.12 cm3, 95% CI -0.24, 0.00) and log2-transformed liver fat percentage (β=-0.28%, 95% CI -0.52, -0.04). Inverse associations were observed between the individual PFAS and most mid-pregnancy OGTT indices and insulin resistance, but were not statistically significant. Associations were not statistically significant for all preconception OGTT indices. Conclusions: We did not find strong evidence for an association between preconception PFAS concentrations and prenatal metabolic outcomes in young women in Singapore. Cross-sectional analyses indicated reduced adiposity in VAT volume and liver fat percentage with increasing PFAS concentration, which requires further investigation in prospective, more diverse, and larger studies.
Presentation: Saturday, June 17, 2023
SAT638 Understanding Heritable Metabolic Alterations Upon Paternal Preconception Nicotine Exposure
Authors: Aguiar Stephanie Rose , Chamorro-Garcia Raquel 
Published: October 2023

Abstract
Disclosure: S.R. Aguiar: None. R. Chamorro-Garcia: None.
Exposure to endocrine-disrupting chemicals (EDCs) found in our environment can increase the risk of susceptibility to metabolic diseases, such as obesity and type 2 diabetes. Tobacco products harbor a cluster of harmful EDCs that are inhaled by smokers and dispersed through the air. Previous research showed that tobacco exposure during pregnancy can lead to developmental alterations that increase the risk of metabolic disease in the offspring later into adulthood. Although global tobacco use is higher among men than women, little is known about how paternal exposure to tobacco products contribute to metabolic disease in future unexposed generations. Paternal preconception exposure to environmental factors have been shown to lead to increased risk of disease in future offspring, though mechanisms of these heritable alterations remain unclear. Our research focuses on determining the mechanisms through which paternal preconception exposure to tobacco-related chemicals, such as nicotine, lead to metabolic disease, and the underlying mechanism of epigenetic inheritance of these metabolic traits. We hypothesize that paternal nicotine exposure elicits alterations in the paternal germline (i.e., sperm) that are transferred to the zygote upon fertilization leading to metabolic alterations in unexposed offspring. We found that paternal preconception exposure to nicotine leads to insulin resistance and increased plasma ghrelin levels in F1 females. In F1 males, we found different metabolic alterations in the form of altered fasting glucose levels and decreased plasma glucagon levels. Taken together, our current data suggest that paternal preconception nicotine exposure may alter ghrelin signaling pathways that lead to metabolic disruption in F1 females, as well as alter glycogen mobilization in F1 males. To determine the mechanism behind these heritable metabolic alterations observed in paternal nicotine-exposed offspring, we will investigate small non-coding RNA populations in the sperm of nicotine-treated sires. We will characterize heritable alterations during early embryogenesis by whole genome transcriptomics. These approaches will identify the mechanisms behind heritable metabolic alterations observed in offspring paternally-exposed to nicotine, as well as indicate what specific transcripts are impacted during early embryogenesis that give rise to these phenotypes. This project will provide insights into the intergenerational metabolically disruptive effects of paternal tobacco use and the mechanism of inheritance that drives these phenotypes, ultimately providing more evidence to change tobacco policies and legislation.
Presentation: Saturday, June 17, 2023
SAT639 Electronic Cigarettes-exposed Mice Have Impairments In Skeletal Muscle Mediated By Impaired Ampk Activation
Authors: Rivera Juan Carlos , Espinoza-Derout Jorge , Hasan Kamrul M , Lao Candice , Wilson Julian Bryant , Shao Xuesi M , Tintut Yin , Jordan Maria , Roos Kenneth P , Sinha-Hikim Amiya P , Friedman Theodore C 
Published: October 2023

Abstract
Disclosure: J. Rivera: None. J. Espinoza-Derout: None. K.M. Hasan: None. C. Lao: None. J.B. Wilson: None. X.M. Shao: None. Y. Tintut: None. M. Jordan: None. K.P. Roos: None. A.P. Sinha-Hikim: None. T.C. Friedman: None.
Electronic cigarettes (E-Cig) are a relatively new way to deliver nicotine (Nic). E-Cigs are gaining popularity, especially among youth and young adults, who do not realize their harmful health effects. Our laboratory has been a pioneer in demonstrating the adverse effects of E-Cigs on the liver and the heart. Skeletal muscle is a bigger tissue with physical and metabolic importance fundamental for human health. We previously reported that IP injection of Nic with a “second-hit” such as a high-fat diet (HFD) caused skeletal muscle damage. This study evaluated the detrimental effects of E-Cigs administration on skeletal muscle. We used an E-Cig inhalation model to deliver Nic in a similar way to humans. C57BL6 mice were fed with an HFD, divided into three groups, and exposed to a saline solution (control group), commercially available E-Cig (bluCig) in absence of Nic (E-Cig 0%), or E-Cig with the presence of Nic (E-Cig 2.4%) for 12 weeks. Results showed that the skeletal muscle exposed to E-Cig 2.4% had a reduction of the phosphorylation of the metabolic regulator, AMPK, and the pro-lipolytic enzyme ATGL as measured by western blot analyses in relation to control saline and E-Cig 0% groups. This metabolic impairment was accompanied by a reduction of the homeostatic mechanism, autophagy by a decrease of the ratio LC3II/LC3I, in the group exposed to E-Cig 2.4% in relation to the saline group. Electron microscopy showed intramyofibrillar mitochondrial with cristolysis, vacuolization, and intramyocellular lipid deposits in the E-Cig 2.4% group. Additionally, we observed an increase in oxidative stress suggested by the increase of the antioxidant enzyme HO-1 in the E-Cig 2.4%, and the reduction of the protein levels of SOD1 and SOD2. Finally, the previous changes trigger the activation of cellular stress pathways such as the phosphorylation of p38 and the increase in inflammasome protein, Nrlp3 in the E-Cig 2.4% compared to the saline group. This study suggests skeletal muscle abnormalities in mice vaping E-Cig 2.4% can alter muscle health. We believe these abnormalities will have important consequences in the skeletal muscle considering the early life stage of the consumers.
Presentation: Saturday, June 17, 2023
THU013 A Rare Case of Ectopic Cushing’s Syndrome Caused By Metastatic Parotid Gland Carcinoma
Authors: Punni Emma , Goyal Itivrita 
Published: October 2023

Abstract
Disclosure: E. Punni: None. I. Goyal: None.
Introduction: Ectopic Cushing’s Syndrome (ECS) is a rare condition that accounts for only a small percentage of all Cushing’s syndrome cases. Although rare, the typical tumors associated with ECS are small cell lung carcinomas, bronchial carcinoids, pancreatic neuroendocrine tumors, medullary thyroid carcinomas, thymic carcinoids and pheochromocytomas. Metastatic acinic cell carcinoma (ACC) of the parotid gland has very rarely been associated with ectopic Cushing’s syndrome. Case Presentation: A 67-year-old Caucasian male with a known diagnosis of high grade metastatic ACC of the parotid gland presented to the hospital with progressively worsening proximal muscle weakness and bilateral lower extremity edema of 6 weeks duration. A month prior to presentation, he developed persistent hypokalemia requiring potassium supplementation and was diagnosed with new onset type 2 diabetes mellitus. Laboratory results on admission were remarkable for low potassium at 2.5 mEq/L (N: 3.5-5.3 meq/L), a random cortisol level of 107 mcg/dL (N: 6 - 30 mcg/dL), and an ACTH level of 485 pg/mL (N: 7.2 - 63.3 pg/mL). Subsequently, a 24-hour urine cortisol was &gt; 1600 ug/24 hours (N 5-64 ug/24 hours). A 1 mg dexamethasone suppression test failed to suppress an 8 a.m. cortisol with level of 110.8 mcg/dl (N &lt; 1.8 mcg/dl). Following, an 8 mg dexamethasone suppression test also failed to suppress 8 a.m. cortisol with a value of 100.8 mcg/dl. A MRI of the pituitary with and without contrast showed mild diffuse enlargement of the pituitary gland concerning for pituitary hyperplasia. At the time, ECS was highly suspected given the rapid course of patient’s presentation, known metastatic malignancy, and failed 8 mg dexamethasone suppression test. An inferior petrosal sinus sampling (IPSS) could not be performed given the patient’s guarded condition. Instead, a PET/CT Ga-68 DOTA-TATE scan obtained showed widespread DOTA-TATE avid malignancy concerning for neuroendocrine type tumor. Patient was a poor surgical candidate, therefore bilateral adrenalectomy could not be performed for the rapid treatment of ECS. Patient was started on a steroidogenesis inhibitor ketoconazole. However, he elected to undergo hospice care and passed away shortly after. Conclusion: This case is particularly interesting given that metastatic ACC of the parotid gland causing ECS is rare with only a few cases reported in the literature. This case highlights the importance of maintaining a high degree of suspicion for diagnosing ECS especially when patients present with rapid onset of signs and symptoms of Cushing’s syndrome and a known underlying malignancy. Recognizing less common causes of ECS may prompt early diagnosis and intervention.
Presentation: Thursday, June 15, 2023
THU014 Post-surgical Remission After Resection Of Solitary Mediastinal Lymph Node In A Metastatic Occult Ectopic ACTH Syndrome Patient
Authors: de Magalhães Isabelle P A , Oliveira Caroline P F , Lins Lais P , Andrade Natália X S , Lima Marcos S , Siqueira Sheila A C , Fonini Jaqueline S , Assis Filho Eudes C , Mariani Alessandro W , Machado Marcio Carlos 
Published: October 2023

Abstract
Disclosure: I.P. de Magalhães: None. C.P. Oliveira: None. L.P. Lins: None. N.X. Andrade: None. M.S. Lima: None. S.A. Siqueira: None. J.S. Fonini: None. E.C. Assis Filho: None. A.W. Mariani: None. M.C. Machado: None.
BACKGROUND: The prevalence of occult cases has been increasing in the most recent series of Ectopic ACTH syndrome (EAS) maybe due to the small size of pulmonary neuroendocrine tumors. We present an atypical and very rare case of EAS with initial presentation of a single metastatic mediastinal lymph node that evolved with remission after your resection with no defined primary tumor. CASE REPORT: A 15-year-old female patient presented a clinical feature of Cushing’s syndrome (CS) with a 1-year evolution. Hormonal evaluation confirmed ACTH-dependent CS: urinary free cortisol of 819 µg/24h (3-43), late night salivary cortisol of 409 ng/dL (&lt;274) and ACTH of 105 pg/mL (&lt;63.3). Noninvasive methods for differential diagnosis of ACTH-dependent CS did not clarify the etiology (conflicting results): pituitary MRI negative, suppression of 59.6% of cortisol after high dose dexamethasone suppression test, positive response of ACTH and cortisol at desmopressin test, suppression of 81% of ACTH at acute octreotide SC test, negative serum tumor markers (gastrin, calcitonin, CEA, CA125, alpha-fetoprotein, CA19.9 and bhCG), negative cervical and pelvic ultrasound, negative computed tomography of thorax and negative abdominal MRI. Bilateral and simultaneous petrosal inferior sinus sampling with desmopressin confirmed EAS due to negative central to peripheral ACTH gradient, even after normalized PRL/ACTH gradients. Finally, PET/CT with Ga68-DOTATATE revealed a single infracarinal nodule of 1.5x0.6 cm with high capture of radioligand, SUVmax of 23.2, suggestive of affected mediastinal lymph node. The patient was submitted to thoracic surgery and the infracarinal lymph node was dissected and removed. Anatomopathological and immunohistochemical analyses disclosed a lymph node metastatic of a well-differentiated grade neuroendocrine tumor ACTH positive, Ki-67 2%. After surgery, the patient exhibited CS improvement and impressive drop of hormones at 5th postsurgical day (serum cortisol &lt;1.0 µg/dL and ACTH of 2.2 pg/mL) confirming remission of CS. CONCLUSION: To our knowledge, approximately 36 cases of EAS due to neuroendocrine tumor of unknown primary origin were reported. However, previous cases commonly exhibited no remission after only removal of metastasis. Our case presented initial remission even with no primary tumor identified (occult primary tumor non-functioning?). Follow up with clinical, hormonal and imaging methods are necessary due to recurrence risk.
Presentation: Thursday, June 15, 2023
THU022 A Case Of Delayed Diagnosis Of Acromegaly
Authors: Blanchard Kayla , Musurakis Clio , Havrylyan Andriy 
Published: October 2023

Abstract
Disclosure: K. Blanchard: None. C. Musurakis: None. A. Havrylyan: None.
A 57-year-old hispanic female with hypertension, prediabetes, hyperlipidemia, and uterine leiomyomata with hysterectomy one year ago presented to our emergency department with sensations of numbness, tingling, and pressure on the top of her head for 12 days’ duration and left eye blurred vision with photosensitivity for 3 days’ duration. Physical exam was significant for evident enlarged facial features including macroglossia, macrognathia, separation of teeth, enlarged lips, enlarged ears and increased size of hands and feet with thickening of the skin on the fingers and toes. Many skin tags were noted on the neck and chest. She reported noticing these changes gradually over the past five years, as well as noticing an increase in shoe size and ring size. Admission labs were significant for IGF-1 965 ng/mL (47-236), Glucagon 172 ng/mL (0.05-8.00), AM cortisol 24 ug/dL (6.7-22.6), ACTH 29.6 pg/mL (7.2-63.3), FSH 13.22 mIU/mL (16.74-113.59), LH 3.79 mIU/mL (10.87-58.64), and Prolactin 24.3 ng/mL (2.74-19.64). Hemoglobin A1c was 5.8% (&lt;5.7) and lipid profile was significant for triglycerides of 202 mg/dL (&lt;150). TSH was within normal limits. A chest x-ray showed no cardiomegaly. An echocardiogram showed no cardiomyopathy. A CT scan of the brain showed a hyperdense sellar/suprasellar mass measuring 2.1 x 0.7 x 2.4 cm with mass effect on the optic chiasm and intracranial optic nerve not excluded. An MRI brain confirmed a large pituitary macroadenoma measuring 2.7 x 2.5 x 2.2 cm with mass effect on the optic chiasm and pituitary stalk. In addition to the above workup, we recommended Neurosurgery evaluation for symptomatic macroadenoma with optic chiasm mass effect, Ophthalmology evaluation for visual fields testing, and referral to a tertiary care center for evaluation and treatment of acromegaly. The patient was discharged with Neurosurgery and Endocrinology outpatient follow-up, but unfortunately did not attend her appointments. Acromegaly is a rare condition with a prevalence of 60 cases per million. While the mean age of occurrence is 32 years, the mean age of diagnosis is 40 to 45 years, highlighting a persisting delay in the diagnosis. The changes associated with acromegaly occur slowly and therefore can be overlooked by the patient, their family members, and even physicians. Left untreated, continued exposure to increased levels of growth hormone and IGF-1 leads to development of comorbidities including Cushing’s disease, cardiovascular disease, diabetes, arthralgias, decreased bone mineral density, sleep apnea, and uterine leiomyomata, as well as increased mortality and decreased quality of life. This case highlights the importance of physicians in all specialties being familiarized with the symptoms and physical features of acromegaly to aid in timely diagnosis.
Presentation: Thursday, June 15, 2023