bluuebunny/crossref_metadata_2025_split huggingface dataset:
ODP116 Proton Pump Inhibitor Induced Hypocalcemia - An Overlooked Cause
Authors: Rivera Krystal , Bhat Geetha 
Published: November 2022

Abstract
Hypocalcemia can be caused by hypoparathyroidism, vitamin D deficiency, GI disorders, or hypomagnesemia. Proton-pump inhibitors (PPIs) which are commonly used for acid reflux symptoms can cause hypomagnesemia leading to hypocalcemia. We report an interesting case of acute hypocalcemia caused by a proton pump inhibitor. A 78-year-old female with a past medical history of follicular thyroid cancer diagnosed in 2008, s/p total thyroidectomy in 2008 followed by radioactive iodine ablation in 2009, was sent to the ER in 2019 for acute hypocalcemia with a calcium level of 6.6 mg/dL found on outpatient labs. Notably, she had no previous history of post-surgical hypoparathyroidism or hypocalcemia after her surgery in 2008. Upon initial evaluation in the ER, she presented with mild numbness, tingling, and weakness preceded by a diarrheal illness. She had concomitant hypokalemia of 3.1 mmol/L and hypomagnesemia of 1. 0 mg/dL for which she received IV and oral electrolyte repletion. She was eventually discharged on oral calcium carbonate, calcitriol, and magnesium. During her outpatient follow up, repeat labs showed persistent hypomagnesemia and low intact parathyroid (PTH) levels. Upon further review of her medication list, she reported continued daily use of omeprazole for acid reflux symptoms for the previous two months prior to her hospitalization. Her magnesium levels remained persistently low despite high doses of replacement. Given her persistently low magnesium and PTH levels, omeprazole was discontinued and she remained on calcium, calcitriol, and magnesium supplementation. Her calcium, and intact PTH levels eventually recovered to normal range and magnesium levels improved. Calcitriol was discontinued. She remained on a low dose of magnesium supplementation. In this patient, the development of her acute hypocalcemia was unlikely related to her remote history of the post-surgical thyroidectomy which occurred eleven years prior. Proton pump inhibitor use is often overlooked when evaluating causes of hypocalcemia. PPIs impair gastrointestinal absorption of magnesium through altering the TRPM6/7 channel affinity of magnesium by decreasing intestinal luminal pH. As a downstream effect, the resulting acute hypomagnesemia is thought to decrease PTH secretion as well as cause PTH resistance, which in turn decreases absorption of calcium, both by the renal and gastrointestinal route. There have been published cases that suggest these electrolyte disturbances commonly occur in elderly women with chronic PPI use. Clinicians should be aware of the effects that PPIs may have on electrolyte abnormalities. As a result, it may be reasonable to monitor magnesium and calcium levels while on a proton pump inhibitor.
Presentation: No date and time listed
ODP119 Raloxifene use after denosumab discontinuation partially attenuates bone loss in the lumbar spine in postmenopausal osteoporosis
Authors: Hone Namki , Kim Kyoungjin , Lee Seunghyun , Rhee Yumie , Shin Sungjae 
Published: November 2022

Abstract

Purpose
Discontinuation of denosumab (DMab) is associated with rapid declinein bone density. Sequential antiresorptive drugs are recommended to preserve bone mass after DMab treatment. It remains unclear whether raloxifene exclusively can be used in certain conditions to attenuate bone loss after DMab discontinuation.

Methods
In this retrospective cohort study, data on postmenopausal women with osteoporosis who discontinued DMab treatment after short-term use (at Severance Hospital, Seoul, Korea, between 2017 and 2021) were reviewed. Changes in bone mineral density (BMD) at 12 months after DMab discontinuation was compared between sequential raloxifene users (DR) and control group without any sequential lantiresorptive (DD). Baseline characteristics were matched through 1: 1 propensity score matching (PSM) without replacement.

Results
A total of 66 patients (DR n=33; DD n=33) were studied. In propensity score matched cohort, mean age was 69.3 ± 8.2 years and T-score for lumbar spine and total hip was -2.2 ± 0.7 and -1.6 ± 0.6, respectively, at the time of DMab discontinuation. Common reason for DMab discontinuation or sequential treatment to raloxifene was invasive dental surgery in DR (n=18, 55%) and ineligibility to obtain insurance reimbursement due to improved BMD in DD (n=18, 55%). Raloxifene caused attenuation of BMD loss (-2.78% vs. -5.80%, p=0. 013)of lumbar spine after adjusting for age, BMI, previous fracture history, lumbar spine T-score at the time of DMab discontinuation, prior bisphosphonate exposure, and DMab injection time.

Conclusion
Raloxifene use after short-term DMab treatment (less than 2.5 years) attenuated lumbar spine BMD loss in postmenopausal women.
Presentation: No date and time listed
ODP121 Recurrent atypical parathyroid adenoma: a case report
Authors: Siqueira Hiloma , Lima Cristiane , Furtado Adriana , Ferreira Alana , Canto Marcelo , Cunha Jéssica , Milward Marina , Faria Erika 
Published: November 2022

Abstract

Background
Atypical parathyroid adenoma is a rare cause of hyperparathyroidism, with an incidence ranging from 0.5 to 4.4%. Its recurrence rate is low, around 3%. We describe a young patient with an atypical parathyroid adenoma that recurred twice at the right neck.

Case presentation
A 39-year-old woman presented to the ER with low back pain, hyporexia, weight loss, and an oral lesion with purulent discharge. She was diagnosed with nephrolithiasis, severe hypercalcemia (serum calcium concentration: 21,2 mg/dl (Reference range 8,5-10,5) and hyperparathyroidism (serum PTH: 703 pg/mL; reference range 15-45pg/mL). Parathyroid scintigraphy identified an uptake at the site of the lower right parathyroid. A cervical US confirmed the presence of a 3 cm markedly hypoechoic nodule in that location. Fine needle aspiration (FNA) suggested parathyroid adenoma, and PTH washout levels were 1900 pg/ml. Screening for multiple endocrine neoplasia was negative. Biopsy of the mandibular alveolar bone, around the oral lesion, showed giant cell lesion. Lower right parathyroidectomy was performed, and the histopathology showed parathyroid neoplasm with features favoring atypical parathyroid adenoma (lesion measuring 3×2×1.8 cm). Fifteen months after the surgery, the patient presented symptoms of hypercalcemia, with a new elevation of serum PTH levels (738 pg/ml), confirmed with radiotracer uptake at the site of the upper right parathyroid gland. She underwent right parathyroidectomy and hemithyroidectomy. Histopathology revealed an atypical parathyroid adenoma. Immunohistochemistry was positive to galectin 3 in rare cells; Ki 67 positive (2%). After nine months, the patient noticed a subcutaneous nodule in the right anterior cervical region associated with symptomatic hypercalcemia, and a new increase in serum PTH levels (469.5 pg/mL). Parathyroid scintigraphy confirmed radiotracer activity at the nodule described, that was surgically resected. Histopathology was compatible with an atypical parathyroid neoplasm (uncertain malignant potential). The patient remains in regular follow-up, asymptomatic and normocalcemic.

Conclusion
While 96% of patients with atypical parathyroid adenomas are cured with parathyroidectomy, this case shows a very rare description of two recurrences in a short time of follow-up, with an ectopic location in the last one. It should be noted that atypical paratyroid adenomas are already an uncommon presentation of primary hyperparathyroidism. Genetic investigation is warranted in such cases.
Presentation: No date and time listed
ODP568 Success of CME at Improving Knowledge, Competence and Confidence Related to Diagnosing and Treating Hypophosphetemic Bone Disease
Authors: Blatherwick Donald , Larkin Amy 
Published: November 2022

Abstract

Introduction
We sought to determine if an online continuing medical education (CME) activity could improve knowledge and competence of endocrinologists (endos) and rheumatologists (rheums) related to diagnosis and treatment of patients with hypophosphatemic bone disease.

Methods
The effect of an online, 30-minute, CME-certified roundtable discussion among 3 faculty was analyzed to determine efficacy. The activity posted November 4, 2020, and data were collected through February 4, 2021.

Results
Overall, 33% of endo learners and 48% of rheum learners improved their knowledge/competence.

Conclusions
This study demonstrates the success of an online 30-minute roundtable discussion on improving knowledge, competence, and confidence regarding diagnosis and treatment of hypophosphatemic bone disease, with gaps identified for future education.
Presentation: No date and time listed
ODP627 Hypercalcemia in a Patient With Gastrointestinal Stromal Tumor (GIST): Evaluation and Treatment Strategies
Authors: Kalra Kriti , Failor Richard A , Nguyen Tiffany T 
Published: November 2022

Abstract
A 52-year-old African woman was found to have a pelvic mass at the age of 41. Following resection of small bowel tumors at the time, she was diagnosed with GIST and peritoneal metastases were confirmed. Despite treatment with imatinib, her disease progressed and was started on regorafenib. Due to lack of consistent insurance coverage, she took this medication intermittently for several years, and her tumor progressed to develop intra-abdominal peritoneal and pelvic metastases. She underwent debulking surgery, and her disease subsequently remained stable with regorafenib. Unfortunately, she developed hemoptysis which led to discontinuation of regorafenib, and while off treatment, the patient developed altered mentation, extreme lethargy, and poor PO intake. She was found to have a serum calcium of 16 mg/dL and was admitted for treatment of severe hypercalcemia. With intravenous (IV) fluids, calcitonin and zoledronic acid, her calcium improved to 11-12 mg/dL; however, despite additional therapies, including denosumab and repeat zoledronic acid, her calcium did not normalize. Further evaluation revealed: 25-hydroxy-vitamin D3 level 22.2 ng/mL (normal), 1,25-dihydroxy-vitamin D3 107 mcg/mL (elevated), PTH 6. 0 pg/ml (low), and PTHrP 3.3pmol/L (low). She was given a diagnosis of calcitriol-mediated hypercalcemia and started on IV hydrocortisone 100 mg every 12 hours. Her serum calcium started to improve within 48 hours and normalized after eight days to 9.8mg/dL. Her clinical condition improved, and she was discharged with prednisone 20 mg daily. At the time of her post-hospital follow up several days later, her serum calcium remained normal.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
OR01-3 Lack of Bone Mineral Density Testing in Men with Hypogonadism: A Clinical Conundrum
Authors: Pantalone Kevin , Goettemoeller Travis 
Published: November 2022

Abstract

Objective
Hypogonadism is a known risk factor for decreased bone mineral density (BMD) and increased risk of fractures in men. The 2012 Endocrine Society Clinical Practice Guidelines recommend that men ≥ 50 years of age with a diagnosis of hypogonadism undergo BMD testing.1 The objective of this study was to determine the frequency at which men aged ≥ 50 with a diagnosis of hypogonadism underwent BMD testing, and among those that underwent testing, the percentage of men diagnosed with osteopenia or osteoporosis and subsequently treated with an osteoporosis medication.

Methods
A retrospective chart review was conducted using the enterprise-wide electronic health record system at our institution. Inclusion requirements were an ICD-9 or -10 code for hypogonadism at any time between 7/1/2012 and 9/30/2020, and at least two subsequent visits with providers from primary care, endocrinology, or urology. Patients with a diagnosis of osteoporosis or who had undergone treatment with an osteoporosis medication, prior to the diagnosis of hypogonadism, were excluded. Patients were followed until the date of BMD assessment or censoring (9/30/2021). The testing results and documentation of treatment with an osteoporosis medication were recorded. Categorical variables and continuous variables were summarized using N (%) and median (IQR) or mean (SD), respectively.

Results
A total of 10,169 men with hypogonadism were identified. General characteristics included mean age of 63.4 years (±9.2), 85.2% white, 52.7% with history of smoking, 68.2% with hypertension, 36.9% with type 2 diabetes, and mean BMI of 31.3 kg/m2 (±6.0). Median follow-up time was 6.6 years (3.8, 8.5). Of 728 (7.2%) patients who underwent BMD testing, 352 (48.4%) had osteopenia and 87 (12.0%) had osteoporosis. A total of 5,633 (55.4%) men underwent treatment with testosterone replacement therapy. Of the 87 patients identified as having osteoporosis, 50 (57.5%) were treated with an osteoporosis medication.

Conclusion
Despite a recommendation from the 2012 Endocrine Society for men ≥ 50 years of age with hypogonadism to undergo BMD testing, the rate at which this testing is performed in real-world practice is quite low. The high rate (60.3%) at which low BMD was discovered in hypogonadal men who underwent testing, and further observation of a low rate of treatment with osteoporosis medication when indicated, is alarming and necessitates a call to action for more hypogonadal men to undergo testing and receive appropriate treatment. Further studies are needed to determine the reasons why so few men with hypogonadism undergo BMD assessment and what systems can be put in place to overcome this clinical conundrum.

Reference
1. Watts NB, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 97, Issue 6, 1 June 2012, Pages 1802–1822, https://doi.org/10.1210/jc.2011-304
Presentation: Saturday, June 11, 2022 12:00 p.m. - 12:15 p.m.
PSAT160 The Dangers of Long-term Aromatase Inhibitor use in an Elderly Hispanic Population
Authors: Acosta Sebastian , Alejandro Angel 
Published: November 2022

Abstract
The most common endocrine therapies for breast cancer are Aromatase Inhibitors (AIs), which can help reduce the recurrence of the disease and its mortality rate. However, because aromatase inhibitors prevent the aromatization of androgens into estrogen, they can have serious effects on bone health. This can lead to accelerated bone loss and an increased risk for fractures, especially among postmenopausal women. In 2017, the Journal of Bone Oncology (JBO) released a joint position statement advising that all patients with breast cancer on endocrine treatment, such as AIs which are known to accelerate bone loss, be placed on bisphosphonate therapy should they present 2 or more risk factors for fracture (1). The purpose of this study was to evaluate patients on AIs at a 5-star Medicare Advantage plan facility and document any discrepancies with regards to whether appropriate treatment is being given to prevent fractures. We hypothesized that we may have a large percentage of patients on AI that have 2 or more risk factors and are not on treatment. An electronic chart review was conducted of 398 patients on AIs between 6/9/2020 and 8/25/2020. Patients were evaluated for the following risk factors: current smoking, personal history of hip/vertebral fracture, current use of glucocorticoids, age &gt; 65, BMD T-score &lt; -1.5, and BMI &lt; 20. Surprisingly, 1 out of every 2 patients treated with an AI was not being treated in accordance with the JBO's recommendations. Of the 398 patients evaluated, 191 presented 2 or more risk factors and were not on antiresorptive treatment. There are a few steps that can be taken to better manage these at-risk patients. First is raising awareness to providers about the dangers of long-term AI use. Additional changes to the EMR system may help as well, such as prompting the ordering provider to consider bisphosphonate therapy if risk factors are present. Lastly, the addition of a fracture reduction clinic can help streamline the referral process to an endocrinologist upon the prescribing of AI therapy. This would allow patients to be fully evaluated for fracture risks and prescribed treatment should they qualify. With the low costs of generic bisphosphonate therapy, if a fracture is prevented, providers can hope to save a significant amount in indirect costs. Through improved awareness of providers of the risks, a more intuitive EMR system, and the creation of a new automatic referral process, we believe that we can vastly improve patient morbidity and quality of life by reducing the chances of fracture in patients on long-term AIs.Reference: (1) Hadji et al., J Bone Oncol. 2017 Mar 23;7: 1-12.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT186 Iatrogenic Calcinosis Cutis in a Patient With Postsurgical Hypoparathyroidism
Authors: Laforteza Alexis Roberto , Ong-Ramos Celeste 
Published: November 2022

Abstract

Clinical Case
A 44-year old woman, diagnosed with post-surgical hypoparathyroidism after total thyroidectomy for papillary thyroid carcinoma, was admitted for symptomatic hypocalcemia. On admission, she had positive Trousseau's and Chvostek's signs, carpopedal spasm and prolonged QT interval on ECG. She had an initial serum ionized calcium of 0.70 mmol/L (RI: 1.09- 1.30). Serum phosphorus was also elevated at 5.8 mg/dL (RI: 2.6-4.7). She was given 2 grams of calcium gluconate via slow IV push and was hooked to calcium gluconate drip, 4 grams in 250 cc D5W to run for 8 hours In less than 24 hours, she developed thrombophlebitis on her right hand, hence the drip was shifted to the left hand. The new IV site also developed phlebitis, necessitating transfer to the right antecubital area. The areas of phlebitis were managed with cold compress, pain relievers, topical antibiotics overlapped with oral antibiotics. She continued receiving calcium gluconate IV drips overlapped with calcium and calcitriol tablets until her serum calcium level normalized. She was discharged stable and improved after 4 days but still with erythema over her previous IV sites. However, 3 weeks after discharge, she developed yellowish erythematous plaques and nodules over her previous IV sites. She consulted with a dermatologist who did a skin punch biopsy showing a granulomatous dermatitis, foreign body type, which confirmed the diagnosis of iatrogenic calcinosis cutis. She was treated with pulse dye laser and intra-lesional triamcinolone, oral antibiotics and pain medications. At present, she still has pain, tenderness, with limitation of movement on both hands. She was referred to a plastic surgeon where she was advised to undergo a total of 3 surgeries over a span of 3-6 months. These would involve the placement of tissue expanders, harvesting of flaps, removal of lesions and reconstruction of scars plus hand rehabilitation after the surgeries.

Conclusion
Iatrogenic calcinosis cutis is a rare complication from extravasation of calcium-containing solutions during intravenous calcium correction. It appears 2-3 weeks after extravasation and has no definitive treatment. In other case reports, it can be managed conservatively but some may require reconstructive surgery. Prevention of extravasation is the only way to avoid this rare and debilitating condition.Reference: Jiménez-Gallo D, Ossorio-García L, Linares-Barrios M. Calcinosis Cutis and Calciphylaxis. Actas Dermosifiliogr. 2015 Dec;106(10): 785-94.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT196 Monostotic Paget's disease of the bone involving the calcaneus
Authors: Eldin Randa Sharag , Haroon Sarah , Shaker Joseph L 
Published: November 2022

Abstract

Introduction
Paget's disease of bone (PDB) is a chronic bone disorder that is fairly common in older age. It is characterized by an initial increase in osteoclastic activity followed by excessive osteoblastic activity with disorganized bone architecture. PDB may involve any bone and may be monostotic or polyostotic. Herein, we report the rare occurrence of monostotic Paget's involving the calcaneus.

Case Description
A 71-year-old white male with PMH of prostate cancer status post radical prostatectomy presented with acute onset severe left heel and ankle pain. Pain was localized to the retrocalcaneal area and heel pad limiting his physical activity. He denied recent trauma. Physical exam was significant for swelling and tenderness of the left heel. Left foot X-rays showed a slightly enlarged calcaneus with very coarse trabeculae consistent with PDB. A total body bone scan done previously because of the prostate cancer showed intense uptake in the left calcaneus but no significant uptake elsewhere. Laboratory workup showed an elevated total serum alkaline phosphatase of 164 U/L (40-129 U/L) and bone specific alkaline phosphatase 65 ug/L (0.0-20 ug/L). He was treated with a single infusion of Zoledronic acid with good clinical response evidenced by improvement in pain and swelling as well as a significant decrease in bone specific alkaline phosphatase to 10 ug/L six months post-infusion.

Discussion
Monostotic PDB only represents about 20% of PDB cases. The pelvis is the most common location followed by the femur as described by Bachiller-Corral et al (Bone, 2013). In our review of the English literature, we found only nine cases of monostotic PDB involving the calcaneus. The mean age of presentation was 60 years old and most of the cases presented as chronic heel pain not responding to conservative pain alleviating measures. Conventional radiography showed the characteristic features of PDB but the changes observed were difficult to differentiate from that of a malignant process. That led to further imaging in most cases by either CT, MRI scan or SPECT scan. Three out of nine patients were reported to receive bisphosphonate therapy with successful remission with a long duration of disease suppression. Good response to therapy highlights the importance of proper diagnosis.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.