bluuebunny/crossref_metadata_2025_split huggingface dataset:
PSAT362 Hypothyroidism Associated Colonic Rupture
Authors: Seetharaman Karthik , Mandava Sri , Wilson Mark 
Published: November 2022

Abstract
A 59 year old female with history of thyroid cancer status post thyroidectomy presented with sudden onset severe and diffuse abdominal pain. CT Abdomen Pelvis with contrast showed extensive pneumoperitoneum suggestive of perforated viscus. The patient was taken to emergent diagnostic laparoscopy showing sigmoid perforation with fecal contamination and multiple large stool balls. Sigmoidectomy and end colostomy was performed for perforated sigmoid diverticulitis with feculent peritonitis. On admission, tests evaluating for thyroid function were consistent with hypothyroidism (TSH 39.700, n 0.400 - 4.500 uIU/mL). Over the previous two years, thyroid function studies were variable with both elevated and low TSH values (range 0.221-117 uIU/ml), although TSH values over the prior 12 months were not elevated. The patient reported adherence to taking levothyroxine 137 mcg daily in the outpatient setting. Furthermore, she endorsed appropriate administration of levothyroxine prior to food and was not taking the medication with any offending vitamins or minerals. Review of systems was negative for alternative causes of colonic rupture including trauma or chronic constipation. A thorough literature review was performed and revealed only 10 cases between 2004-2007 of spontaneous perforation of the colon in the absence of tumors, diverticulosis, or external injury.1 Only two reports were found linking spontaneous perforation of the colon with hypothyroidism, and proposed the causative mechanism as intestinal motility dysfunction causing chronic constipation, megacolon, or even pseudo-obstruction eventually leading to stercoral perforation.[2-3] Hypothyroid status was addressed by increasing levothyroxine dosage to 150 mcg daily. The patient recovered from septic shock and performed a 2 week course of inpatient rehabilitation from which she was discharged home with good functional status. Follow up labs evaluating thyroid status will be performed 4-6 weeks after initial testing and are still pending.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT378 Hashimoto's Thyroiditis and Differentiated Thyroid Cancer Aggressiveness
Authors: Mushref Malek , Bridges Matthew , Chandran Keshav , Mukherjee Rupak , Javid Mahsa 
Published: November 2022

Abstract

Background
Hashimoto's thyroiditis (HT) is associated with a 1.5-fold increased risk of differentiated thyroid cancer (DTC). It is postulated that the inflammatory milieu in HT may damage thyrocytes, increasing the risk of cancer. However, it is not precisely known how the presence of thyroiditis affects aggressiveness of DTC and if a causal relationship exists. It has been suggested HT may correlate with a less aggressive phenotype with smaller tumor size, lower rate of aggressive variants, less frequent radioactive-iodine administration, and higher rates of clinical remission. The aim of this study was to investigate the pathological features of DTC in patients with HT and whether length of time with HT affects tumor aggression.
Method
Charts of 367 consecutive patients with DTC undergoing thyroidectomy were reviewed. Clinical and pathological factors were analyzed. A composite score of tumor aggressiveness was calculated using the presence of multifocality, angioinvasion, lymphatic invasion, extrathyroidal extension, central and lateral lymph node (LLN) involvement. This score and tumor size were compared in patients with clinical (elevated thyroid peroxidase or anti-thyroglobulin antibodies) or pathological (presence of inflammation on pathology) HT. Time to surgery from diagnosis of HT was also evaluated.

Results
In 367 patients with DTC (343 papillary, 29 follicular, 5 both), mean size of the largest tumor was 1.5±1.7cm, mean composite score was 1.3±1.6cm. Seventy-three (19.9%) and 156 (42.5%) patients had clinical or pathological HT, respectively; 92 (25.1%) had preoperative hypothyroidism.
Patients with clinical HT alone, or in addition to pathological HT, had a reduced risk of LLN disease (Odds Ratio: 0.21 p&lt;0.005, and OR: 0.43 p=0.01, respectively); those with pathological HT alone had a trend towards lower risk (p=0.06). Neither the overall score for tumor aggressiveness nor tumor size correlated with clinical or pathological HT.
Length of time from diagnosis of clinical HT to surgery was not associated with tumor size, aggressiveness or presence of inflammation on pathology.

Conclusion
Clinical HT is associated with reduced risk for LLN metastasis, supporting the suggestion that presence of HT confers a better prognosis in DTC. Length of time with HT does not alter the risk for aggressive features of DTC indicating lack of an escalating causal relationship.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
PSAT388 A Rapidly progressive papillary thyroid carcinoma presenting 22 years after RAI therapy
Authors: Norwich Diana , Kotla Nishitha , Kirkeby Kjersti 
Published: November 2022

Abstract
The risk of thyroid cancer following RAI therapy remains controversial. We report a case of an aggressive papillary thyroid carcinoma presenting over twenty years after RAI therapy for Graves’ disease.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.
RF23 | PSAT240 Suboptimal Thyroid Hormone Replacement is Associated with Worse Hospital Outcomes
Authors: Bianco Antonio C , Ettleson Matthew , Laiteerapong Neda , Wan Wen 
Published: November 2022

Abstract

Introduction
Many patients in the US with hypothyroidism receive suboptimal treatment with thyroid hormone. Sustained off-target TSH levels have been shown to cause serious harm to patients, including increased risk of cardiovascular disease and excess mortality over time. Suboptimal treatment may also impact hospital outcomes. The primary objective of the study was to identify differences in hospital outcomes between patients with and without hypothyroidism.

Methods
This is a retrospective cohort study that utilized the propensity score-based fine stratification method to balance covariates. Patient data was extracted from a large, US-based, IBM MarketScan® Commercial Claims and Encounters Database from January 1, 2008 to December 31, 2015. Participants included patients 64 years and younger who had commercial insurance and a thyrotropin (TSH) level collected prior to a medical or surgical hospital admission. Covariates included age, sex, US region, type of admission (medical vs surgical), year of admission, and co-morbidities. The primary exposure was defined as clinical hypothyroidism, which was divided into 4 subgroups based on pre-hospitalization TSH level: low (TSH &lt;0.40 mIU/L), normal (TSH 0.40–4.50 mIU/L), intermediate (TSH 4.51–10.00 mIU/L), and high (TSH &gt;10.00 mIU/L). Non-hypothyroidism was the non-exposure (control). The primary outcomes were length of stay (LOS), in-hospital mortality, and readmission outcomes following medical and surgical admission.

Results
A total of 46,235 patients were included in the final study population, of whom 9,394 had a diagnosis of hypothyroidism. Those with a high pre-hospitalization TSH level had a LOS that was 1.2 days longer (95% CI [1.1–1.3]; p = 0.001), a 41% higher risk of 30-day readmission (RR 1.41, 95% CI [1.13–1.75]; p = 0.002), and 33% higher rate of 90-day readmission (RR 1.33, 95% CI [1.13–1.56]; p &lt;0.001) compared to balanced controls. Patients with intermediate TSH levels exhibited increased likelihood of 30-day readmission (RR 1.20, 95% CI [1.01–1.43]; p = 0.04). Conversely, those with a normal pre-hospitalization TSH level had a decreased risk of in-hospital mortality (RR 0.55, 95% CI [0.34–0.89]; p = 0.02) and 90-day readmission (RR 0.91, 95% CI [0.85–0.99]; p = 0.02).

Conclusions
Suboptimal treatment of hypothyroidism appears to be associated with worse hospital outcomes, including longer LOS and higher rate of readmission. Public health strategies designed to deliver appropriate, consistent outpatient treatment of hypothyroidism are needed to improve hospital outcomes in those patients with off-target TSH levels.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 12:30 p.m. - 12:35 p.m.
RF23 | PSAT259 Comparable Bioavailability of a Novel Levothyroxine Solution when Administered with Coffee
Authors: Washington Kris , Baron Michelle , Vandse Sunil 
Published: November 2022

Abstract
Levothyroxine (LT4) is the treatment of choice for hypothyroidism and the second most prescribed medication in the United States. Despite its established efficacy and widespread availability, approximately 40% of patients treated with LT4 fail to achieve thyroid stimulating hormone (TSH) levels within the normal range. Current LT4 product guidelines recommend administration in the fasting state 30-60 minutes before breakfast to avoid a food interaction leading to reduced intestinal absorption of LT4. This recommendation may impact compliance, as over 50% of adult Americans drink coffee every day, 65% of which is consumed during breakfast.While the majority of patients receive LT4 tablets, there is evidence that liquid formulations that bypass the gastric dissolution phase may mitigate the interference with coffee. ThyquidityTM (levothyroxine sodium) oral solution has demonstrated bioequivalence to Synthroid® under fasting conditions and allows individualized dosing flexibility in a variety of clinical scenarios. A bioavailability study was conducted to assess the rate and extent of absorption of the oral LT4 solution (100 mcg /5 mL) administered with coffee compared to administration under fasting conditions in an open label, randomized, two-period, two-treatment, two-sequence, crossover, single dose bioavailability study in 40 healthy adults. A single 600 μg oral dose of LT4 solution (ThyquidityTM, 30 mL) was administered 5 minutes before drinking 8 ounces of American coffee (without milk or sweeteners) or under fasting conditions in each study period. Blood samples were collected for total (bound and free) T4 for 48 hours after drug administration. Treatment periods were separated by a 40-day wash-out period.The ratios of geometric LS means with corresponding 90% confidence intervals (CI) were calculated from the exponential of the difference between the LT4 solution administration 5 minutes prior to coffee and administration under fasting condition for AUC0-48 and Cmax. An absence of a food effect would be concluded if the baseline corrected 90% CIs of this ratio fell within 80.00% to 125.00% for Ln-transformed AUC0-48 and Cmax.Forty healthy adults participated in the trial. There were no serious adverse events (AE) or discontinuations due to AEs. The geometric LS mean ratio of AUC0-48 and Cmax for baseline-adjusted LT4 were 93.98% (90.06-98.07%) and 95.99% (92.64- 99.45%) respectively. The corresponding 90% CIs were included within the acceptance range for bioequivalence.This study demonstrated comparable bioavailability of a single oral 600 μg dose of Thyquidity oral solution administered, 5 minutes prior to coffee or under fasting conditions. These results are consistent with earlier evidence that liquid LT4 overcomes the interference from coffee seen with LT4 tablets and may offer additional flexibility for patients.
Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Sunday, June 12, 2022 1:06 p.m. - 1:11 p.m.
LBODP070 A Rare Neuroendocrine Tumor-Insulinoma
Authors: Sekhon Navharsh , Medina Dionardo 
Published: November 2022

Abstract

Introduction
Insulinoma is a rare neuroendocrine tumor, which presents sporadically or as a complex of multiple endocrine neoplasia type 1 syndrome (MEN-1). Most Insulinoma cases present with fasting hypoglycemia and some with both fasting and postprandial hypoglycemia.

Case Report
A 48-year-old male with no significant past medical or surgical history presented for an evaluation of hypoglycemia. He was recently seen in the Emergency Room after having a transient ischemic attack-like episode. The patient reported that he was at a family gathering where he was found confused and his blood glucose was checked by a family member with diabetes, which was noted to be 39 mg/ dl. He reported having other such episodes of lesser severity, occurring once or twice a month for many years. His symptoms would typically wake him from sleep, especially during early mornings with diaphoresis. He would take a snack to resolve his symptoms. Except for being overweight, no other abnormal findings were detected on physical examination. Fasting blood work revealed glucose of 42 with elevated insulin, C-peptide, proinsulin levels, and negative beta-hydroxybutyrate and insulin antibodies. An MRI abdomen with contrast demonstrated a 1.2 cm pancreatic lesion in the uncinate process, suspicious for a neuroendocrine tumor. Endoscopic Ultrasound staged the mass in the uncinate process of the pancreas as T1 N0 M0. FNAC showed a few atypical monomorphic cells suggestive of neuroendocrine origin. Immunohistochemical stains on the sample were positive for CD45 while CAM5.2, synaptophysin, and Ki65 were negative. The patient ultimately underwent exploratory laparotomy and resection of the neuroendocrine tumor with partial pancreatectomy.

Discussion
The symptoms of hypoglycemia are classified into sympathoadrenal (palpitation, diaphoresis, tremulousness) or neuroglycopenic (confusion, blurry vision, change in behavior, seizures, and amnesia of hypoglycemic episode). The neuroglycopenic symptoms of hypoglycemia mimic transient ischemic attack (TIA). The diagnosis of insulinoma needs biochemical proof of endogenous hyperinsulinemia and localization of the tumor. Surgery is the treatment of choice in resectable tumors.

Conclusion
This case highlights insulinoma as a rare cause of hypoglycemia and shows the importance of detailed history taking and appropriate investigations in its diagnosis. References: 1. Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, Kobayashi M, Hanazaki K. Diagnosis and management of insulinoma. World J Gastroenterol. 2013 Feb 14;19(6): 829-37. doi: 10.3748/wjg. v19. i6.829.2. Mathur A, Gorden P, Libutti SK. Insulinoma. Surg Clin North Am. 2009 Oct;89(5): 1105-21. doi: 10.1016/j. suc.2009. 06. 009.3. huo F, Anastasopoulou C. Insulinoma. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.
Presentation: No date and time listed
ODP553 Hypoglycemia after sleeve gastrectomy: a rare case of an insulinoma
Authors: Ferreira-Hermosillo Aldo , Lobaton-Ginsberg Miry , del Pilar Sotelo-Gonzãlez María , Ramírez-Rentería Claudia , Juãrez-Aguilar Fany Gabriela 
Published: November 2022

Abstract

Background
The obesity pandemic has become a great topic of interest due its implications for quality of life, comorbidities, increasing mortality and the economic impact on health services worldwide(1). Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective and durable treatment for severe obesity and glucose metabolism disorders, achieving weight loss due to its restrictive and humoral effects (2). Its prevalence has increased from 5 to 37% since 2008 (3). One common complication after bariatric surgery (BS) is the postprandial hyperinsulinemic hypoglycemic state (4). While rare, insulinomas can cause it, where symptoms are more common during the fasting state; thus, evaluation of insulin secretion is needed to exclude dumping syndrome or nesidioblastosis. Until now, this is the first report of insulinoma after LSG.

Clinical Case
We here present 43-year-old women who was referred to the Obesity Clinic two years after LSG was performed. She had symptoms of hypoglycemia predominantly in the fasting state with a documented glycemic level of less than 30 mg/dl, compatible with Whipple's Triad. Initially, we suspected dumping syndrome but after documentation of a second low fasting plasma glucose, we decided to perform a 72-hour fasting test, which tested positive. Computed tomography and endoscopic ultrasound were performed, identifying the presence of a homogeneous hypoechoic semioval tumoral lesion in the pancreas. The diagnosis was compatible with insulinoma. A laparoscopic enucleation of insulinoma was performed, and after that, the hypoglycemic symptoms and blood sugar levels improved, remaining asymptomatic until now. The histopathological report described a well-differentiated grade 2 neuroendocrine tumor with positive chromogranin and synaptophysin and Ki67 immunopositivity in 4% of the neoplastic cells.

Conclusion
This is the first case of insulinoma after sleeve gastrectomy, the suggested physiopathology is due to a combination of increased plasma concentrations of incretins, mainly glucagon-like peptide 1 (GLP-1), and an accelerated release of nutrients in the proximal duodenum (5). Although this is a very rare case condition, clinicians must be aware of it, especially if the patient has hypoglycemic symptoms during the fasting state. References: 1) Rev Med Inst Mex Seguro Soc. 2016;54(2): 118–23; 2) J Clin Gastroenterol. 2021;55(7): 551–76; 3) Obes Surg. 2017;27(12): 3179–86; 4) HHS Public Access. 2017;10(1): 1–14; 5) Diabetes Metab. 2011;37(4): 274–81.
Presentation: No date and time listed
ODP554 insulinoma with a delayed diagnosis of 25 years
Authors: Boharoon Hessa , Caplin Martyn , Grossman Ashly 
Published: November 2022

Abstract

Introduction
Most insulinomas are rare pancreatic neuroendocrine tumours that are typically sporadic, solitary, with the great majority less than 2cm in diameter at presentation 1; fewer than 5% of insulinomas are larger than 3cm, and in such cases are not infrequently malignant. The median duration of symptoms before diagnosis is variable, but is usually brief, often just 12–18months, although longer durations are occasionally reported. We report the case of a benign insulinoma whose diagnosis was delayed for 25 years, and who eventually presented with a relatively large but benign tumour &gt;4cm in diameter.

Case presentation
The patient was a50year-old male who presented to our service with a history of hypoglycaemia episodes dating back 25 years. The first, whilst living in Pakistan, he became unwell on his wedding day and was found to have an unspecified but very low blood glucose, confirmed at his local hospital. Since that time, he reported that he had "learned to live with the symptoms" by eating frequent small carbohydrate-rich meals, although missing a meal led to typical hypoglycaemic symptoms. He continued this regimen on moving to the UK, but over a recent period of three months he reported a substantial deterioration in his symptoms(confusion, disorientation, slurred speech, generalised weakness, tachycardia and palpitations), and indeed collapsed on two occasions. He had a fasting glucose of 2.9 mmol/L with grossly elevated and inappropriate insulin and C-peptide level, with a normal cortisol response to Cosyntropin. MRI demonstrated asingle4.1cm lesion in the body of the pancreas, however 68 Gallium-DOTATATE-PET scanning showed no uptake at any site. Accordingly, he was started on diazoxide 50mg tds and referred to the surgical team for distal pancreatectomy: histopathology revealed a 4.4 cm well-differentiated pancreatic neuroendocrine neoplasm of intermediate grade (NET G2, 2017 WHO Pancreatic-NET classification) which immunostained positive for insulin. Post-operatively, his hypoglycaemic episodes have ceased and he remains under active surveillance.

Conclusion
The great majority of insulinomas are small benign tumours, with a short history, with large tumours often indicating malignancy. Our case demonstrates that untreated and without specific therapy, such tumours may continue to grow and attain a large size without this indicating malignant potential. 68 Gallium-DOTATATE-PET is negative in more than 50% of benign insulinomas. We believe that this represents the longest survival, 25 years, of a patient with a benign insulinoma in the absence of treatment.
Presentation: No date and time listed
ODP561 Unilateral Vestibular Schwannoma as the Presentation and Aggravation to be Severe Primary Hyperparathyroidism
Authors: Kiatpanabhikul Phatharaporn 
Published: November 2022

Abstract

Background
A rare benign and slow-growing tumor as vestibular schwannoma (acoustic neuroma) usually presents with asymptomatic/unilateral hearing loss or tinnitus and loss of balance between the ages of 49 to 60 years. 90% of vestibular schwannoma are unilateral and not specifically grown in patients with neurofibromatosis type2 (NF2) (1). The association of schwannoma and parathyroid adenoma has been published not much but consistently until now. However, those were not mention to the relationship between pre- and post-treatment of schwannoma with parathyroid hormone level. Clinical case: A 65-year-old woman, previously healthy, presented with progressive fatigue and loss of balance for 1 month. She developed hearing loss, dysarthria and facial palsy within 1 week. At her first visited, she looked drowsiness and had slow verbal and motor response with right facial palsy, lower motor neuron type. She lost only her right facial sensation by pinprick and hyperreflexia without significant other neurological deficits and abnormal skin lesions. She denied family history of NF2. Severe hypercalcemia (17.66 mg/dL) with markedly elevated parathyroid hormone (PTH 1,115.1 pg/mL; 15-68.3) levels and mild elevation of serum creatine (Cr 1.32 mg/dL) was revealed. MRI brain showed an extra-axial enhancing mass at right CPA-IAC region size 3.7×4.2×2.9 cm possible vestibular schwannoma, this mass causing pressure effect to right sided of pons, medulla, cerebellar hemisphere and fourth ventricle. After treatment with saline hydration, her serum creatinine was recovered to normal range with slightly high normal serum calcium (11.85 mg/dL) but not being well. She came back to hospital again with fatigue and polyuria for 3 days. Her serum calcium rose up to 21.3 mg/dL with very high PTH level; 1,643 pg/mL and elevation of serum creatine (Cr 1.71 mg/dL). Again, she was treated with saline hydration for 3 days before receiving zoledronate 4 mg intravenously. After that her serum calcium and creatinine returned to normal level (Ca 10.32 mg/dL, Cr 1. 08 mg/dL) with being better. She was undergone surgery for removal right vestibular tumor and proved to be schwannoma in pathology. During further investigation of hyperparathyroidism, she had normocalcemia and her PTH level dropped to about 400 pg/mL.

Conclusion
Our patient showed the contribution of vestibular schwannoma to rise up the level of PTH as same level as parathyroid carcinoma. There could be some relationships of mechanism between there two diseases that should be explored further. Reference: 1. Carlson ML, Link MJ. Vestibular Schwannomas. Review article. N Engl J Med 384;14,Apr 8, 2021.
Presentation: No date and time listed