bluuebunny/crossref_metadata_2025_split huggingface dataset:
ODP065 Impact of Comorbid Adrenal Insufficiency on Outcomes During Hospitalization For Cardiogenic Shock
Authors: Kumi Dennis D , Ramirez Marcelo , Nissan Ninos , Patel Birju , Soon-shiong Raquel , Shrestha Prajwal , Karki Sadicchya 
Published: November 2022

Abstract

Background
The catabolic stress associated with cardiogenic shock requires a robust metabolic, neuroendocrine, and immunologic response to mitigate, and adrenocortical hormones play a huge role in this process. On the other hand, excessive aldosterone production is known to play a key part in the long-term progression of myocardial insufficiency through myocyte remodeling. It is thus intriguing to understand how adrenocortical insufficiency impacts the outcomes of patients admitted for cardiogenic shock. Method: A retrospective cohort study was designed using data obtained from the 2016 to 2018 combined National Inpatient Sample (NIS) database. Adult patients (age &gt;18) with principal admission diagnosis of cardiogenic shock were identified using the international diseases classification code, tenth revision (ICD 10), and separated into two cohorts based on the presence of a secondary diagnosis of adrenal insufficiency. Primary outcomes assessed were, mortality, length of stay (LOS) and total hospital charge. Secondary outcomes evaluated included rate of mechanical ventilation, mechanical circulatory support device use and cardiac arrest. Multivariate linear and logistic regressions were used to adjust for confounders.

Results
There was a total of 477,695 adult hospitalizations for cardiogenic shock, out of which 1.28% had associated secondary diagnosis of adrenal insufficiency. There was a statistically insignificant increased odds of mortality among patients with adrenal insufficiency (33.42% vs 33.35%, AOR: 1. 05, 95% CI: 0.93 to 1.19, p: 0.462). There was also an increased length of stay (18.91 days vs 11.35 days, adjusted mean difference: 6.5 days, 95%CI: 5.22 days to 7.78 days, p &lt; 0. 001) and an increased total charge (364,864.5 vs 238,591.9 USD, adjusted mean difference: 105,491.9 USD, 95%CI: 78,252.2USD to 132,731.3 USD, p &lt; 0. 001) among patients with adrenal insufficiency compared with the counterpart cohort group and these were statistically significant. Patients with adrenal insufficiency also had 42% increased odds of being mechanically ventilated during cardiogenic shock admission compared to patients without (55.67% vs 46.61%, AOR: 1.42, 95%CI: 1.26 to 1.60, p &lt; 0. 001). Other secondary clinical outcomes assessed, including mechanical circulatory support devices use and cardiac arrest were not statistically different between the two groups.

Conclusion
Adrenal insufficiency as a comorbid diagnosis among patients admitted with cardiogenic shock was associated with increased odds of requiring mechanical ventilation, prolonged length of stay and higher total hospital charges. There was a trend towards increased mortality, but this was not statistically significant. There was no difference in other clinical outcomes including mechanical circulatory support devices and cardiac arrest rate.
Presentation: No date and time listed
PMON284 Triamcinolone Cream-Induced Cushing Syndrome
Authors: Sacco Susana Barreiro , Francisco Barrera Echegoyen Francisco , Ferri-Guerra Juliana , Hannoush Zeina 
Published: November 2022

Abstract

Introduction
Iatrogenic Cushing syndrome (CS) is typically due to systemic corticosteroids. Less frequently, it can be caused by inhaled, ocular, intra-articular, and topical glucocorticoids.
There are multiple reported cases of pediatric CS due to topical corticosteroids, this is partly due to this patient's population thinner dermis which allows for higher absorption. In adults, there are few reported cases of iatrogenic CS secondary to Clobetasol, one of the highest potency topical steroids available. We present a unique case of severe Iatrogenic CS secondary to topical Triamcinolone in a patient with no medications that could interfere with glucocorticoid metabolism.

Case
A 30-year-old-female with Type 2 Diabetes Mellitus and psoriatic arthritis was admitted with generalized psoriatic lesions affecting 70% of her body surface area (BSA) and non-healing open wounds affecting two thirds of her upper legs. The leg wounds had failed to improve after seven washouts and three skin grafts in the course of four months. Additionally, she reported recent weight gain and a new diagnosis of hypertension. Pertinent physical exam findings included moon facies, dorsocervical fat pad, acanthosis nigricans, and open wounds in 67% of bilateral upper legs. Subsequently, her cortisol was found to be 1.2 mg/dL (6.2-19.4 mg/dL) with an ACTH level of 1.2 pg/mL (7.2-63.3 pg/mL). ACTH stimulation test confirmed adrenal insufficiency.
The only medication she was prescribed for psoriasis at the time of admission was 0.1% Triamcinolone cream. She had been applying the steroid to over 50% of her BSA, including open wounds, for the past four months. Upon admission, Triamcinolone was discontinued, and she was started on cyclosporine and a TNF inhibitor for psoriasis management as well as oral hydrocortisone for adrenal insufficiency. Three months later, during her last office visit, her facial rounding and plethora, dorsocervical fat pad and hypertension had moderately improved.

Discussion
To the best of our knowledge, this is the first reported case of adult iatrogenic CS secondary to topical Triamcinolone in the absence of any drug-drug interaction. Purser et al reported Triamcinolone induced CS in an HIV patient taking Ritonavir, a cytochrome P450 inhibitor that increases the amount of active steroid. Our patient had increased absorption due to the application of the cream to a large BSA and to open wounds. The two main factors that determine the development of iatrogenic CS are the potency of the glucocorticoids and the duration of exposure. The pathophysiology of wound healing in CS has been well studied and reported, therefore, the objective of this report is to understand how a relatively benign topical medication can have detrimental systemic effects.
Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.
LBSAT290 Papillary Thyroid Cancer Discovered After Benign Afirma Gene Testing, A Case Report
Authors: Ahmad Mobeen , Thelmo Franklin , Ucciferro Peter 
Published: November 2022

Abstract

Introduction
Grave's disease is an autoimmune form of hyperthyroidism characterized by antibody stimulation of the thyrotropin receptor. Although there are conflicting study results, patients suffering from Grave's disease appear to have an increased incidence of thyroid cancer. Fine needle aspiration helps detect potential carcinoma, however, it is indeterminate in 15-30% of cases. In cases where fine needle aspiration of a thyroid nodule returns Atypia of Undetermined Significance (AUS) or Follicular Lesion of Undetermined Significance (FLUS), next-generation sequencing, including Afirma gene testing (created by Veracyte inc) provides guidance for therapy. However, like any screening test, the chance for false negatives still exists. We describe the case of a 41-year-old man suffering from Grave's disease with a solitary thyroid nodule which was found to be papillary thyroid carcinoma despite benign Afirma gene testing.

Case description
A 41-year-old male with no past medical history presented to his primary care provider with no active complaints but was found to have a blood pressure of 142/92 mmHg. He notably had a diffusely enlarged thyroid gland on examination. The patient was sent for thyroid function testing which demonstrated TSH: &lt; 0. 01 uIU/ml and a free T4: 1.1 ng/dL. The patient was sent for a thyroid ultrasound which demonstrated a right-sided nodule measuring: 3.5 cm×2.4 cm×3.2 cm (TI-RADS 4). Radioactive idodine uptake scan revealed this was a cold nodule and the patient underwent fine-needle aspiration biopsy and Afirma gene testing. The patient's biopsy demonstrated AUS while Afirma gene testing was benign. After discussing treatment options for Grave's disease with his endocrinologist, the patient underwent total thyroidectomy. Post-surgical biopsy of the patient's thyroid demonstrated follicular variant papillary thyroid carcinoma with capsular invasion. The patient is currently being followed closely by endocrinology with regular TFT and thyroglobulin testing.

Discussion
Grave's disease is postulated to increase patients’ risk of developing papillary thyroid cancer. Many of the proposed hypotheses explaining this higher risk center around thyroid-stimulating antibodies promoting tumor invasion and angiogenesis. When these patients demonstrate suspicious thyroid nodules on imaging, they undergo fine-needle aspiration, however, these biopsies are indeterminate in 15-30% of cases. Afirma gene testing has been proposed as a sensitive test to rule out carcinoma in these indeterminate cases. We describe a case where, despite benign Afirma gene testing, the patient was found to have papillary thyroid cancer after thyroidectomy. We propose that Grave's disease patients with suspicious nodules with indeterminate biopsy and benign Afirma testing still be considered for total thyroidectomy given their increased risk of thyroid cancer.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
ODP467 CDC Clinical Standardization Programs (CSP) for Free Thyroxine (FT4) to improve the accuracy and reliability of FT4 measurements in patient care and clinical research
Authors: Sugahara Otoe , Ribera Ashley , Danilenko Uliana , Collins Lynn , Buchannan Tatiana , Coffman Clark , Vazquez Norma , Pokuah Fidelia , Zhang Li , Lyle Alicia N , Hubert Vesper , Thonkulpitak Janet 
Published: November 2022

Abstract
Concerns about the accuracy and reliability of thyroid function tests, especially free thyroxine (FT4), have been stated by the clinical laboratory community for many years. Thyroid function tests are the most used tests in the U. S. and are the only means to detect and treat diseases of the thyroid. The consequences of inadequate thyroid hormone levels can be severe and are easily preventable and treatable with early detection. In response to these concerns, the CDC CSP has partnered with the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) and created a standardization program for FT4 based on the IFCC reference system. The CDC program aims to improve the accuracy, reliability, and comparability of current methods and, thus, improve the diagnosis, treatment, and prevention of thyroidal illnesses. There were no commutable, certified serum-based FT4 reference materials (RMs) available to assess the accuracy and reliability of FT4 assays. CDC has developed an accurate and sensitive reference measurement procedure (RMP) to assign reference values to individual donor sera. Assay manufacturers and research and clinical laboratories can use these sera to assess the analytical performance of their measurements, and monitor performance over time. In addition, the CDC's FT4 RMP is used to assign reference values to materials used in EQA/PT programs to verify that standardization efforts at the developer level translate to the end-user level. The CDC FT4 RMP uses equilibrium dialysis (ED), based on an internationally recognized ED procedure, followed by solid-phase and solvent extractions before analysis by LC-MS/MS. Certified primary RM IRMM468 is used as calibrators. The intra- and inter-day imprecision of the CDC RMP are 3. 0% and 1.1%, respectively. The CDC RMP measurement range is 3. 02–258 pmol/L, which is suitable for analysis of hypo- and hyperthyroid patients. Based on an IFCC comparison study between four FT4 RMPs, the CDC RMP's bias was within 2.5% of the all-labs mean. CDC CSP is currently conducting a comparison to further define the differences among various types of commercially available FT4 assays. A set of 40 serum RMs value assigned with the FT4 RMP are now available via the Phase 1 of the Hormone Standardization (HoSt) Program. These materials can be used for calibration and verification by assay developers. CDC CSP is currently working to develop a Phase 2 of the HoSt Program for FT4 to assist developers with certification of FT4 assays. Based on the needs and requests from the clinical community, programs for new biomarkers, such as thyroid-stimulating hormone, are also being developed.
Presentation: No date and time listed
ODP504 PERICARDIAL EFFUSION AS A LIKELY CONSEQUENCE OF NON-COMPLIANT MANAGEMENT OF HYPOTHYROIDISM
Authors: Rimal Priya , Zbarsky Dmitri , Musurakis Clio , Havrylyan Andriy , Barsano Charles 
Published: November 2022

Abstract
Hypothyroidism is a well-known cause of pericardial effusion with an incidence of about 3-27%. If not diagnosed in time it can lead to potentially serious complications, such as cardiac tamponade leading to hemodynamic instability. It should be considered as a causative or exacerbating agent in any patient presenting with pericardial effusion and known, suspected or laboratory evidence of hypothyroidism, e. g., elevated TSH or reduced serum free T4. We present a case of a 50-year-old woman with a Past Medical Hx of hypertension, intermittently insulin-treated type 2 diabetes for 20 years, coronary artery disease, and hypothyroidism with medical non-compliance, and s/p right BKA. She initially presented to an outside hospital for altered mental status (specifically, inability to follow simple commands and orientation only to self). She was transferred to this facility for evaluation of limb ischemia. She was agoitrous with no reported palpable thyroid abnormalities. Her admission chest x-ray exhibitedan enlarged cardiac silhouette. Her initial serology was significant for a serum TSH of 178 uIU/mL (NL: 0.45-5.33 uIU/mL), FreeT4 &lt;0.25 ng/dl (NL: 0.58-1.64 ng/dl),Free T3 1.65 pg/mL (NL: 2.5-3.9 pg/mL), andhighly elevated anti-thyroglobulin and anti-peroxidase antibodies. She was diagnosed as having primary hypothyroidism secondary to Hashimoto's thyroiditis. She was re-started on levothyroxine (L-T4) at a dose of 150 mcg on day 1, which was reduced to 100 mcg daily on days 2-4 but readjusted to 125 mcg daily on days 5-8 and 150 mcg daily thereafter. During the 25 th day of admission in the Rehabilitation unither serum TSH showed a gradual decline from 178 to 22 prior to discharge. Her Free T4 increased to 1.18 and her Free T3 increased to 2.24 by discharge. Her pericardial effusion was managed by placement of a pericardial window. Pericardiocentesis yielded over 600 ml of clear serous fluid (protein content 5.1 gm/dl) without evidence of malignancy, infection or inflammation. This case highlights the importance of not only recognizing the diagnosis of hypothyroidism but of assessing the duration and adequacy of its management. Likewise, an enlarged cardiac silhouette in this setting should be considered as possibly representing a pericardial effusion and impending source of a cardiac tamponade.
Presentation: No date and time listed
ODP508 PRIMARY DIFFUSE LARGE B-CELL THYROID LYMPHOMA: A CASE REPORT
Authors: Tan Margarita Katrina Amor , Ty Wilson , Uy Melissa Claire 
Published: November 2022

Abstract

Background
Primary thyroid lymphoma (PTL) is a rare disease, accounting for &lt;5% of all thyroid malignancies. Diffuse B-cell lymphoma (DBCL) is the most common type of PTL. The diagnosis and management of PTL depends on the histopathologic results.

Clinical Case
A 77-year-old female (with T2DM, Hypertension and CAD) had sudden onset of rapidly enlarging neck mass associated with compressive symptoms such as dyspnea, dysphagia and hoarseness of voice. She underwent neck CT scan with contrast revealing a heterogenous mass on right thyroid lobe 9.7×6.9×5.5 cm, with encasement and invasion of adjacent portions of trachea and right common carotid artery . Thyroid function tests were normal and anti-TPO was elevated at 1891.76 IU/ml (NV: &lt; 5.6 IU/mL). Patient underwent tracheostomy and excision biopsy of the mass. Histopathologic report showed atypical lymphoid proliferation and Hashimoto's thyroiditis. Immunohistochemical staining of the neoplastic cells were reactive to CD20, CD3; and Ki67 was positive in 70-90%. Fluorescence in situ hybridization test for c-myc, BCL 6 rearrangement and IGH/BCL 2 fusion for ruling out aggressive double-hit lymphomas came out negative, hence the final diagnosis of Non-Hodgkin's Diffuse Large B-cell Lymphoma. Most PTL originate from B cells, especially DBCL, which accounts for 50–80%. A standard management in PTL is controversial due to limited clinical trials and due to its heterogenous nature. A multidisciplinary approach is the best management technique for PTL. Chemotherapy can cause remission but recent studies showed better response with chemoradiotherapy. The patient was started on R-CVP (rituximab, cyclophosphamide, vincristine, prednisolone). One year after, FDG-PET showed resolution of right thyroid lobe mass with mild diffuse metabolic activity in the rest of thyroid gland, and absence of hypermetabolic lymph nodes.

Conclusion
In older patients presenting with a rapidly enlarging goiter, especially in a setting of Hashimoto's thyroiditis, the diagnosis of PTL should be considered and differentiated from other types of thyroid disease. The prognosis and management of PTL differ from secondary thyroid lymphoma and other types of neoplasm. It can have a good outcome when recognized in earlier stages and if with less aggressive histopathologic type.
Presentation: No date and time listed
ODP526 Thyrotoxic Periodic Paralysis in Graves’ Disease: A rare presentation in an African American male
Authors: Ghoweba Mohamed , Jain Sidharth , Patel Nisargi 
Published: November 2022

Abstract
INTRODUCTION: Thyrotoxic Periodic Paralysis is a rare but life-threatening manifestation of hyperthyroidism characterized by hypokalemia, acute flaccid paralysis, and signs of hyperthyroidism. Despite being commonly seen in East Asian males, TPP has been increasingly reported in other parts of the world including western countries. Early recognition and prompt treatment of TPP is essential in preventing its grave and potentially life-threatening consequences. CASE PRESENTATIONA 21-year-old African American male patient with past medical history significant for hypertension and untreated hyperthyroidism presented to the emergency department with sudden onset bilateral lower extremity weakness and difficulty walking for one day. Upon arrival to the emergency department, vitals were unremarkable. On examination, patient had a decreased muscle tone in bilateral lower extremities with depressed deep tendon reflexes. The thyroid gland was diffusely enlarged. The remainder of physical exam was normal. Electrolyte abnormalities were also present with decreased serum potassium level of 1.2 mEq/L (3.6-5.1 mEq/L) and magnesium of 1.7 mg/dL (1.8-2.5 mg/dL). A low TSH level of &lt;0. 010 mIU/mL (0.350-4.940 mIU/mL) with elevated free T4 levels of 4.30 ng/dL (0.70-1.48 ng/dL) were noted. CT Head/ Brain without contrast and Chest X ray were unremarkable. Potassium replacement was initiated with oral and intravenous potassium chloride. He was also started on oral atenolol (25 mg daily) and methimazole (10 mg daily). The patient's symptoms resolved in few hours after the treatment was started. An ultrasound of the thyroid gland showed diffuse heterogeneity of the gland most consistent with thyroiditis or similar abnormality. No definite focal abnormalities were noted. TSH receptor antibodies were also elevated with levels at 10.70 IU/L (≤1.75 IU/L) making Graves’ disease the most likely diagnosis. The patient's condition significantly improved along his hospitalization with complete resolution of symptoms and electrolyte abnormalities. He was subsequently discharged on atenolol and methimazole with outpatient follow up at the endocrinology clinic. DISCUSSION TPP is an underreported yet possibly fatal medical complication of hyperthyroidism. Prevalence is higher in Asia, however, incidence in Western countries has been increasing. While the underlying pathophysiology is poorly understood, h ypokalemia in TPP results from an intracellular shift of potassium induced by an increased adrenergic sensitization of Na + /K + –ATPase pump. Genetic and environmental factors may possibly play a role. Treatment of TPP entails beta-blockade to prevent intracellular shift of potassium, replenishing potassium stores, as well as correcting the underlying hyperthyroid state. Immediate diagnosis and initiation of treatment prevents serious cardiopulmonary complications and increases the probability of full recovery of muscle weakness.
Presentation: No date and time listed
ODP527 To Treat or Not to Treat Pembrolizumab-Induced Thyroiditis: Using Common Terminology Criteria for Adverse Events as a Decision-Making Aid
Authors: Alatrash Batool , Arnouk Nelly , Cheikh Malek , Mohebtash Mahsa , Schroeder Pamela 
Published: November 2022

Abstract

Introduction
Programmed cell death-1 (PD-1) checkpoint inhibitors are immunotherapeutic agents that are used to treat advanced malignancies including breast cancer. The adverse effects of these medications include thyroid and pituitary dysfunction and may be treated with glucocorticoids, which may cause steroid-induced effects such as hyperglycemia, osteoporosis, and adrenal suppression. The Common Terminology Criteria for Adverse Events (CTCAE) widely used by oncologists for management can support treatment decisions by endocrinologists in patients undergoing treatment with PD-1 checkpoint inhibitors.

Case Description
A 42-year-old female with stage IIIc high-grade triple negative left breast invasive ductal carcinoma was started on pembrolizumab immunotherapy (PD-1 inhibitor). Prior to starting treatment, the patient's thyroid function tests were normal: free T4 0.93 ng/dL (normal range [NR] 0.89-1.76 ng/dL) and thyroid-stimulating hormone (TSH) 1.42 uIU/mL (NR 0.55-4.78 uIU/mL). Two weeks later, she developed heat intolerance, diarrhea, weight loss, and dysphagia. At that time, thyroid tests were consistent with thyrotoxicosis with elevated total T3 644.6 ng/dL (NR 60-180 ng/dL) and totalT4 &gt;12. 00 ng/dL with suppressed TSH 0. 01 uIU/mL. Despite negative TSH receptor antibody and thyroid-stimulating immunoglobulin, CT scan of the neck showed diffuse enlargement of the thyroid gland and thickening of the extraocular muscles. On physical examination she had mild exophthalmos. The etiology of thyrotoxicosis was initially thought to be Graves’ disease, but thyroiditis could not be ruled out. Treatment with methimazole and beta blockers was initiated. Three weeks after methimazole was started, her symptoms improved significantly, with repeat thyroid function tests: TSH 3.64 uIU/mL and free T4 1.29 ng/dL. Methimazole was held. Four weeks later, the second dose of pembrolizumab was administered. Later that day, repeat thyroid function tests showed high TSH 53.12 uIU/ml, and low T4 0.55 ng/dL with negative thyroid-stimulating immunoglobulin and thyroid peroxidase antibodies, consistent with thyroiditis. Endocrinology and Oncology teams discussed the CTCAE determining that the severity of thyroiditis was grade 2 (moderate symptoms, able to perform activities of daily living, TSH persistently above 10 uIU/L). Pembrolizumab was continued and hypothyroidism was treated with levothyroxine.

Discussion
CTCAE is used by oncologists to aid in treatment decisions in patients treated with PD-1 inhibitors. Endocrinologists should consider using the CTCAE grading (severity) scale for each adverse event. Adoption and utilization of the CTACE severity scale by endocrinologists may lead to a more standardized and systematic approach for treatment of thyroid disorders associated with PD-1 inhibitor immunotherapy
Presentation: No date and time listed