Fasciitis ossificans: imaging features, histology, and differential diagnosis

AIM

To describe the imaging features of fasciitis ossificans and its histopathological features.

MATERIALS AND METHODS

Using a word search of existing pathology reports at the Mayo Clinic, six cases of fasciitis ossificans were identified. The clinical history, histology, and available imaging of the affected area were reviewed.

RESULTS

Imaging consisted of radiographs, mammograms, ultrasound images, bone scintigraphs, computed tomography (CT), and magnetic resonance imaging (MRI) images. All cases demonstrated a soft-tissue mass. The characteristic MRI appearance was a T2 hyperintense enhancing mass with surrounding soft-tissue oedema. Peripheral calcifications were seen on radiographs, CT, and/or ultrasound. Histological sections showed distinct zonation, with nodular fasciitis-like zones of myofibroblastic proliferation, which merged with osteoblasts that rim the ill-defined trabeculae of woven bone and became continuous with the mature lamellar bone surrounded by a thin layer of compressed fibrous tissue.

CONCLUSION

Imaging features of fasciitis ossificans are that of an enhancing soft-tissue mass located within a fascial plane with prominent surrounding oedema and mature peripheral calcification. Imaging and histology are that of myositis ossificans but occurring within the fascia. It is important that radiologists are aware of the diagnosis of fasciitis ossificans and appreciate its similarity to myositis ossificans. This is particularly important in anatomical locations with fascias but no muscle. Given the radiographic and histological overlap between these entities, nomenclature that encompasses both could be considered in the future.

Adherence to standard of care (SOC) therapy for the treatment of metastatic hormone-sensitive prostate cancer (mHSPC): A single-institution analysis

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Background: Androgen deprivation therapy (ADT) has been the backbone of treatment for mHSPC for decades. In recent years, multiple randomized controlled trials demonstrating an overall survival (OS) benefit of combination treatment (e.g. ADT + novel hormonal agent and/or chemotherapy) has made this the current SOC. Large real-world reports have shown a significant number of patients are still being treated below the SOC with ADT alone, but these databases do not include patient level data to help understand the rationale for treatment decisions. We reviewed our institution’s treatment patterns for mHSPC to better understand why some patients are being treated with ADT alone. Methods: We conducted a retrospective analysis on patients who initiated treatment for mHSPC from 2017-2021 at Cleveland Clinic. Patient characteristics were recorded, including age and histology. Treatment characteristics, including location of treatment, treatment regimen, and treatment rationale (if not treated with SOC) were noted. Results: Four hundred forty-nine patients were included, with diagnosis of metastatic disease made at a median of 63 years, of which 446 started treatment with systemic therapy. The vast majority of patients were managed by a medical oncologist (95.5%). About half of the patients (49.8%) received treatment at the main campus, with the remaining patients being treated at an affiliated regional hospital (28.7%) or outpatient medical center (21.5%). Additional characteristics are shown. Out of the 446, 40 (9.0%) patients received ADT alone. Reasons for ADT monotherapy included patient preference (n = 13), cost (n = 2), and poor functional status/comorbidities (n = 4). Twenty (50%) of the patients who got ADT alone had no documented rationale for why this treatment plan was elected. One patient was lost to follow-up. For patients who received only ADT, 12 were treated at main campus, 20 were treated at a regional hospital, and 8 were treated at an outpatient medical center. Conclusions: At our institution, adherence to treatment up to SOC for mHSPC was better than previous real-world reports. There were documented reasons for not treating mHSPC up to SOC combination therapy for half of the patients who got ADT monotherapy. It remains unclear why the remaining half did not get combination therapy up to the SOC. [Table: see text]

External validation of the SAVED score for venous thromboembolism risk stratification in patients with multiple myeloma receiving immunomodulatory drugs

Selective patients with multiple myeloma (MM) receiving immunomodulatory drugs (IMiD) are at high risk for venous thromboembolism (VTE). The SAVED score is a VTE risk prediction model recently incorporated into the National Comprehensive Cancer Network (NCCN) guidelines. Using retrospective data from 501 MM patients with new IMiD initiation between 2010 and 2019, we performed the first independent external validation of this model. The cumulative incidence of VTE after IMiD initiation at 6 and 12 months was 32% and 42% in the high-risk group, versus 6% and 9% in the low-risk group respectively. The C-statistic of the SAVED score to predict VTE within 12 months of IMiD-based treatment start was 0.74 [95% confidence interval (CI): 0.69-0.78], which outperformed several other VTE risk models in MM patients. Our findings suggest that the SAVED score is an accurate risk assessment tool for VTE stratification in patients initiating IMiD-containing regimens.

Recent Advances in Adult Post-Transplant Lymphoproliferative Disorder

PTLD is a rare but severe complication of hematopoietic or solid organ transplant recipients, with variable incidence and timing of occurrence depending on different patient-, therapy-, and transplant-related factors. The pathogenesis of PTLD is complex, with most cases of early PLTD having a strong association with Epstein-Barr virus (EBV) infection and the iatrogenic, immunosuppression-related decrease in T-cell immune surveillance. Without appropriate T-cell response, EBV-infected B cells persist and proliferate, resulting in malignant transformation. Classification is based on the histologic subtype and ranges from nondestructive hyperplasias to monoclonal aggressive lymphomas, with the most common subtype being diffuse large B-cell lymphoma-like PTLD. Management focuses on prevention of PTLD development, as well as therapy for active disease. Treatment is largely based on the histologic subtype. However, given lack of clinical trials providing evidence-based data on PLTD therapy-related outcomes, there are no specific management guidelines. In this review, we discuss the pathogenesis, histologic classification, and risk factors of PTLD. We further focus on common preventive and frontline treatment modalities, as well as describe the application of novel therapies for PLTD and elaborate on potential challenges in therapy.

Protocol for a multi-phase, mixed methods study to develop and evaluate culturally adapted CBT to improve community mental health services for Canadians of south Asian origin

Background

Canadians of South Asian (SA) origin comprise the largest racialized group in Canada, representing 25.6% of what Statistics Canada terms “visible minority populations”. South Asian Canadians are disproportionately impacted by the social determinants of health, and this can result in high rates of mood and anxiety disorders. These factors can negatively impact mental health and decrease access to care, thereby increasing mental health inequities. Cognitive Behavioural Therapy (CBT) in its current form is not suitable for persons from the non-western cultural backgrounds. Culturally adapted Cognitive Behavioural Therapy (CaCBT) is an evidence-based practice. CaCBT is more effective than standard CBT and can reduce dropouts from therapy compared with standard CBT. Thus, CaCBT can increase access to mental health services and improve outcomes for immigrant, refugee and ethno-cultural and racialized populations. Adapting CBT for growing SA populations in Canada will ensure equitable access to effective and culturally appropriate interventions.

Methods

The primary aim of the study is to develop and evaluate CaCBT for Canadian South Asian persons with depression and anxiety and to gather data from stakeholders to develop guidelines to culturally adapt CBT. This mixed methods study will use three phases: (1) cultural adaptation of CBT, (2) pilot feasibility of CaCBT and (3) implementation and evaluation of CaCBT. Phase 1 will use purposive sampling to recruit individuals from four different groups: (1) SA patients with depression and anxiety, (b) caregivers and family members of individuals affected by anxiety and depression, (c) mental health professionals and (d) SA community opinion leaders. Semi-structured interviews will be conducted virtually and analysis of interviews will be informed by an ethnographic approach. Phase 2 will pilot test the newly developed CaCBT for feasibility, acceptability and effectiveness via quantitative methodology and a randomized controlled trial, including an economic analysis. Phase 3 will recruit therapists to train and evaluate them in the new CaCBT.

Discussion

The outcome of this trial will benefit health services in Canada, in terms of helping to reduce the burden of depression and anxiety and provide better care for South Asians. We expect the results to help guide the development of better services and tailor existing services to the needs of other vulnerable groups.

Trial registration

ClinicalTrials.gov NCT04010890. Registered on July 8, 2019

Current Utilization Trends of SGLT-2 Inhibitors in Type 2 Diabetics With Heart Failure

Background: Sodium glucose cotransporter-2 inhibitors (SGLT2 inhibitors) are a recent addition to the armamentarium for treating type 2 diabetes. Over the last couple of years, these agents have been studied in patients with cardiovascular disease, particularly heart failure. Results of the EMPA-REG (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), CANVAS (Canagliflozin Cardiovascular Assessment Study) and DECLARE-TIMI (Dapagliflozin Effect on Cardiovascular Events-Thrombolysis in Myocardial Infarction) have clearly shown SGLT2 inhibitors to be beneficial for patients with heart failure. FDA has approved Canagliflozin and Dapagliflozin for reduction of risk of adverse cardiovascular events in patients with Type 2 Diabetes with established Cardiovascular disease. This study was conducted to determine the current utilization trends of SGLT2 inhibitors in Type 2 Diabetics admitted with congestive heart failure exacerbation at Abington Memorial Hospital. Methods: The study was an observational retrospective chart review of 287 patients who were admitted to the telemetry floor with an admitting diagnosis of Congestive Heart Failure with a concomitant diagnosis of Type 2 Diabetes from 06/01/2019 to 11/30/2019. 186 patients met the inclusion criteria. Results: Mean age of the patient population was 69 years. Mean ejection fraction was 39%. Mean A1C was 7.7. Out of 186 patients who met the inclusion criteria, 2 patients were on SGLT2 inhibitor on admission and were discharged on it. 1 patient was started on a SGLT2 inhibitor during hospitalization and was discharged on it. Out of our patient population, only 1.6% of the patients were discharged on SGLT2 inhibitor. Conclusion: Even after FDA approval of SGLT-2 inhibitors in reducing heart failure hospitalizations in patients with known history of Type 2 diabetes and heart failure, the utilization of these drugs is very minimal. No other drug has been proven to improve mortality in patients of heart failure with preserved ejection fraction. Based on the results of this study, we propose that initiation of SGLT2 inhibitor should be one of the core measures during discharge of Type 2 Diabetics after a hospitalization with Heart Failure.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

MON-614 Degree of Diabetes Control Determines the Admission Severity of Diabetic Ketoacidosis

Objectives: To determine whether the degree of diabetes control correlates with the admission severity of diabetic ketoacidosis (DKA).

Methods: A Retrospective chart review was performed for patients admitted with DKA to the medical ICU at Abington Memorial Hospital between January 1, 2017 and January 1, 2018. Laboratory Data required to determine an acute physiology and chronic health evaluation (APACHE) score, hemoglobin A1C, length of hospital stay was recorded. The APACHE score was used to determine the severity of disease at admission. Patients were divided into two groups: low severity (APACHE <15) and high severity (APACHE >15).

Results: A total of 50 patients were included in the analysis. The mean age of the patients was 47 yrs (range 17-85 yrs). 52%(n=26) of the population were males. The overall mean APACHE II at admission was 15 (range 3-28). The low severity group (APACHE <=15) and high severity group (APACHE >15) were equally matched at 25 patients each. The mean APACHE scores were 9.9 and 18.7 for the low and high severity groups respectively. The mean hemoglobin A1C values for the low and high severity groups were 10.5 and 15 respectively. The average length of ICU/hospital stay was 1.6/3.65 and 1.54/3.61 days for the low and high severity groups respectively.

Conclusions: According to our study, a higher severity of DKA (higher APACHE) was associated with a higher hemoglobin A1C level. However, the study did not find any difference in the average length of ICU/hospital stay between the two groups.

SAT-239 Combination of Immune Check Point Inhibitors Causing Hypopituitarism

Introduction: Immune Check Point inhibitors (ICI) have been associated with immune related adverse events including a wide array of Endocrinopathies particularly when a combination of ICIs is used. We present a case of Hypopituitarism secondary to CTLA-4 inhibitor Iplimumab and PD-1 inhibitor Pembrulizumab in a patient with Vulvar Melanoma.

Case Description: 49-year-old female with past medical history of Type 2 Diabetes and Vulvar Melanoma presented with nausea, vomiting and fatigue. The patient had surgical excision of Vulvular Melanoma and had been on chemotherapy with Pembrolizumab and Ipilimumab for 1 month. She was found to be hypotensive in the ER, but blood pressure improved after fluid resuscitation. Her blood sugar levels were 76 MG/DL. She denied using any insulin in the last 24 hours. AM Cortisol was <1 UG/ML. TSH was 0.205 UIU/ML with free T4 at 0.74 NG/DL. FSH was 2.5 MIU/ML. LH was 0.5 MIU/ML. Prolactin was 90.2 NG/ML. ACTH was less than 9 PG/ML. MRI of the brain showed mildly enlarged pituitary gland with suprasellar extension, measuring 10.5 mm in craniocaudal height and normal homogeneous enhancement. A diagnosis of Hypopituitarism secondary Ipilimumab and Pembrolizumab was made. She was started on steroids and thyroid replacement. The patient’s symptoms resolved, and she was discharged home in a stable condition with outpatient Endocrinology follow up.

Discussion: Immune checkpoint inhibitors (ICI) includes PD1(Programmed cell death receptor 1) inhibitors like Pembrolizumab and CTLA-4 (Cytotoxic T Lymphocyte Antigen-4) inhibitors like Ipilimumab. CTLA-4 inhibitors have more frequently been associated with Hypophysitis leading to particularly ACTH and TSH deficiencies and causing secondary adrenal insufficiency and secondary hypothyroidism. Posterior Pituitary involvement is less common. MRI usually shows mild to moderate enlargement of the pituitary gland. ICI therapy usually does not need to be stopped. Patients commonly require long term glucocorticoid and thyroid replacement.

SUN-183 Adrenalitis Induced by Nivolumab

Introduction: Tumor cells often express a programmed death-ligand 1 (PD-L1), which binds to the programmed death receptor-1 (PD-1) on activated T-cells to induce immune tolerance. Among the class of immune checkpoint inhibitors (ICI), Nivolumab is an anti-PD-1 antibody which blocks these tumor cell interactions. Although some endocrinopathies have been reported for other PD-1 inhibitors, the adverse event of adrenalitis with nivolumab has not been reported before. Clinical Case: A 65-year-old female presented to the hospital with complaints of nausea, vomiting, fatigue, and headache for five days. She was recently diagnosed with metastatic lung adenocarcinoma, complicated by cerebellar metastases, and the left cerebellar mass was resected. She was also started on Nivolumab. Her blood pressure was 98/65 mmHg on the presentation. Serum sodium was 122mEq/L (normal 135–145) and potassium was 5mEq/L (3.5–5). TSH, LH, and prolactin were all normal. Aldosterone was low: 23pmol/L (27.7–582.5) and renin was high: 11 ng/ml/h (0.167- 1.38). Morning cortisol levels were low: 2.2 ug/dl (5- 25) and concomitant ACTH was high: 78 pg/ml (7.2- 63.3). Upon standard high dose cosyntropin stimulation test, basal cortisol was 2.0 ug/dl (5- 25). Cortisol level 30 minutes post cosyntropin was 7.1 ug/dl, while Cortisol 60 minutes post cosyntropin was 12.2 ug/dl (normal >18 -20 ug/dl). Considering the low cortisol levels with high ACTH, and an inadequate rise in cortisol after the ACTH stimulation test, adrenal insufficiency was suspected as a result of adrenalitis due to Nivolumab. Hyponatremia along with low aldosterone and high renin levels also reinforced this clinical diagnosis. A computerized tomographic scan of the chest abdomen and pelvis only showed calcified uterine fibroids. She was initially resuscitated with intravenous fluids. Hydrocortisone 100 mg every 8 hours was started and then gradually tapered down to 60mg every 12 hours. Fludrocortisone was also initiated at 0.2mg daily. Symptoms began to improve, and sodium levels normalized to136 mEq/dl. She was discharged on 30mg of hydrocortisone and 0.1 mg of fludrocortisone daily and is stable since then. Conclusion: This is a rare case of Nivolumab-induced adrenalitis. It highlights the importance of checking for adrenal insufficiency in a patient who presents with symptoms of hypotension and hyponatremia while being on ICI drugs, as unidentified adrenal insufficiency and adrenal crisis can be fatal.

Are Linear Measurements of the Nucleus Basalis of Meynert Suitable as a Diagnostic Biomarker in Mild Cognitive Impairment and Alzheimer Disease?

BACKGROUND AND PURPOSE

Cell loss within the nucleus basalis of Meynert is an early event in Alzheimer disease. The thickness of the nucleus basalis of Meynert (NBM) can be measured on structural MR imaging. We investigated NBM thickness in relation to cognitive state and biochemical markers.

MATERIALS AND METHODS

Mean bilateral nucleus basalis of Meynert thickness was measured on coronal T1-weighted MR imaging scans from the Alzheimer's Disease Neuroimaging Initiative dataset. Three hundred and fifteen scans (80 controls, 79 cases of early mild cognitive impairment, 77 cases of late mild cognitive impairment and 79 cases of Alzheimer disease) were assessed. Alzheimer's Disease Assessment Scale-Cognitive scores, CSF tau, and amyloid quantification were extracted. Group differences in NBM thickness, their correlates and measurement reliability were assessed.

RESULTS

Mean NBM thickness ± SD progressively declined from 2.9 ± 0.3, 2.5 ± 0.3, and 2.3 ± 0.3 to 1.8 ± 0.4 mm in healthy controls, patients with early mild cognitive impairment, late mild cognitive impairment and Alzheimer disease respectively (P < .001). NBM thickness was negatively correlated with Alzheimer's Disease Assessment Scale-Cognitive scores (r = -0.53, P < .001) and weakly positively correlated with CSF amyloid (r = 0.250, P < .001) respectively. No association with CSF tau was found. NBM thickness showed excellent diagnostic accuracy to differentiate Alzheimer disease (area under the curve, 0.986) and late mild cognitive impairment from controls (area under the curve, 0.936) with excellent sensitivity, but lower specificity 66.7%. Intra- and interrater reliability for measurements was 0.66 and 0.47 (P < .001).

CONCLUSIONS

There is progressive NBM thinning across the aging-dementia spectrum, which correlates with cognitive decline and CSF markers of amyloid-β pathology. We show high diagnostic accuracy but limited reliability, representing an area for future improvement. NBM thickness is a promising, readily available MR imaging biomarker of Alzheimer disease warranting diagnostic-accuracy testing in clinical practice.

SAT-594 A Metabolic Muddle : Thyrotoxicosis Causing Diabetic Ketoacidosis

INTRODUCTION: Diabetic Ketoacidosis (DKA) is a metabolic state developing in diabetic patients whenever a stressor shifts the metabolism towards ketogenesis with resultant metabolic acidosis. Common stressors for DKA are infections and medication non-compliance. We present a peculiar case of DKA which was precipitated by thyrotoxicosis. CASE DESCRIPTION: 32-year-old female with past medical history of Type 1 Diabetes Mellitus presented for evaluation of nausea, vomiting and chest pain. She reported as being compliant with her insulin regimen. Physical examination showed rapid breathing and acetone breath. Initial blood tests revealed elevated blood sugars at 745 MG/DL with a high anion gap metabolic acidosis. Beta hydroxybutyrate levels were elevated suggesting diabetic ketoacidosis. Rest of the workup to identify the precipitating cause, including urinalysis, EKG, Chest X ray had been negative. Another striking feature noted on patient's examination was bilateral exophthalmos. No thyroid enlargement was appreciated. A thyroid function panel was ordered which demonstrated elevated free T4 at 3.42 NG/DL (normal range 0.7-1.9 NG/DL), T3 at 26.01 PG/ML (normal range 1.7-3.71 PG/ML) and a depressed TSH level <0.01 mcIU/mL (normal range 0.35-.5 mcIU/ml) suggesting primary hyperthyroidism. Our patient improved upon administration of IV fluids and insulin with resultant closure of anion gap and resolution of DKA. Tachycardia persisted despite the resolution of DKA. Treatment was begun with propylthiouracil and propranolol to control thyrotoxicosis with remarkable improvement at the time of discharge. DISCUSSION: Treatment of Diabetic Ketoacidosis requires a thorough investigation of the precipitating event. In clinical practice, the most common triggers are noted to be infections like pneumonia and urinary tract infections, missed or inadequate insulin dose and myocardial infarction. Hyperthyroidism is rarely considered as a culprit for the same. In literature, there is only mention of few cases of hyperthyroidism causing DKA. Hyperthyroidism affects glucose and insulin metabolism in multiple ways. In untreated hyperthyroidism, proinsulin processing becomes abnormal resulting in a reduced C peptide to pro insulin ratio. Hyperthyroidism also leads to increased glucose absorption in the intestinal tract. Lastly, excessive thyroid hormone activity reduces the half-life of insulin via increased degradation into biologically inactive molecules. Our case emphasizes the need to consider thyrotoxicosis as an independent risk factor for development of DKA in appropriate clinical settings, especially when tachycardia persists despite resolution of DKA and infection has been ruled out. Women with Type 1 Diabetes have been found to have a higher prevalence of Graves’ disease. Correction of underlying hyperthyroidism decreases the insulin requirements in these patients.

SAT-586 Primary Fallopian Tube Carcinoma Metastasizing to the Thyroid Gland: A Rare Cause of Hypothyroidism

Background: Primary fallopian tube carcinoma (PFTC) has been considered to account for only about 0.1-0.5% of all gynecologic cancers. It is notorious for metastasis to the ovaries, omentum, and uterus but has never been reported to present with hypothyroidism as a metastatic thyroid nodule. Case: A 53-year-old female presented with fatigue, generalized weakness and constipation for the last 4 months. Her past medical history was significant for stage IV poorly differentiated PFTC status post total abdominal hysterectomy, omentectomy and tumor debulking due to the local spread of the PFTC. She also underwent multiple cycles of chemotherapy with paclitaxel, cisplatin, doxorubicin and bevacizumab and was declared in remission by her oncologist. On examination, her vital signs were stable. Thyroid examination showed palpable nodules in the right and left lobes. Her laboratory investigation revealed normal liver and renal function tests, but the blood chemistry was significant for raised TSH levels of 68.8 mcIU/ml and decreased T3 and T4 levels of 45 ng/dL and 0.54 ng/dL respectively. Thyroid Peroxidase Antibody level was less than 3 IU/ml (reference range <6 IU/ML). Thyroid ultrasound showed a 2.3 x 0.7 x 2 cm solid nodule in the medial lower pole of the right lobe with and a 1.9 x 0.8 x 1.1 cm solid nodule in the medial lower pole of left lobe with increased vascularity. The fine needle aspiration cytology revealed groups of highly atypical cells showing enlarged, irregular, crowded nuclei which were intermixed with scattered bland follicular cells and macrophages. These atypical cells were identical to the serous carcinoma cells seen on previous PFTC specimens, confirming the hematogenous spread of PFTC to the thyroid gland. This diagnosis was further substantiated by immunohistochemical staining, which showed two different populations of cells, thyroid cells stained positive for TTF-1 (Thyroid transcription factor-1) while other cells were positive for WT-1 immunohistochemical stain strongly suggestive of metastatic serous carcinoma. Her serum cancer antigen 125 (CA 125) was also found to be elevated at 395 U/ml (normal range 0-35 U/ML) suggesting recurrence of PFTC. Niraparib chemotherapy was initiated. She was also started on 75 mcg of Levothyroxine per day. TSH levels after two months were 4.2 mcIU/ml. Conclusion: PFTC can be diagnosed early in its course using transvaginal Doppler ultrasound to detect areas of neovascularization within the fallopian tube. PFTC has histological and clinical resemblance with ovarian and uterine primaries and hence can be challenging to diagnose. It is incredibly uncommon to suspect thyroid metastasis from the residuals of PFTC as a possible etiology of hypothyroidism. Thus, physicians should keep a very high index of suspicion in appropriate clinical settings. Prognosis remains poor as most patients present with metastatic disease.

SUN-136 Know Your Patients: Our Experience with DKA in the Suburbs

Background: A variety of precipitating factors and clinical presentations have been identified for Diabetic Ketoacidosis (DKA). Most of the available data is from inner city hospitals which cater to a specific demographic much different from suburban medical centers. This study was performed at a suburban community hospital to analyze disease and demographic characteristics of patients admitted with DKA. Methods: Data was retrospectively collected from electronic medical record review for patients admitted with DKA between January 1, 2017 and January 1, 2018. Data included demographics, medical history, hemoglobin A1C, ancillary laboratory tests and length of hospital stay. Patients who left against medical advice were excluded. For patients with multiple DKA admissions, only the first admission was analyzed. Per hospital policy, all DKA patients were admitted to the medical intensive care unit. Results: 55 hospitalizations met the inclusion criteria involving 50 patients. 5 out of 55 patients had readmissions for DKA. The mean age was 47(range 17-85) years. 52% (n=26) of the population were males. The patient population comprised of 52% (n=26) African Americans, 48 % (n=24) Caucasians and 2%(n=1) other ethnic groups. The most common presenting symptom was nausea/vomiting reported by 48% (n=24) of the study subjects. Lethargy/fatigue, abdominal pain was the second and third most common reported symptom by 30% (n=15) and 26% (n=13) subjects respectively. Other presenting symptoms were polyuria 20%(n=10), polydipsia 18%(n=9), confusion 18%(n=9), weakness 12%(n=6), headache 4%(n=2) and blurring of vision 2%(n=1). The above reported symptoms were not mutually exclusive. The most common precipitant for DKA was medication noncompliance 44%(n=22) which was comparable in African American (11/26) and Caucasian (11/24) subgroups. This was followed by infectious etiologies in 36%(n=18) of the cases. DKA was the first presentation of undiagnosed DM in 10%(n=5) of the subjects. Steroid use was implicated in 4%(n=2) patients. Insulin pump failure was implicated in one subject. No definite cause was identified in 4%(n=2) of the patients. Mean hemoglobin A1C was 12.5% (range 8.2-12.5). The mean acute physiology and chronic health evaluation score (APACHE II) at admission was 15 (range 3-28). There was no mortality in the study population. The average length of hospital stay was found to be 3.7 days. Conclusions: (1) Suburban patients with DKA have subtle differences in characteristics as compared to inner city residents and more studies are required to explore these characteristics. (2) Elevated hemoglobin A1C reflects the need for better long-term glycemic control even in patients reporting good compliance. (3) Medication noncompliance rates appear to be independent of ethnicity. (4) Despite high APACHE scores, DKA remains a low mortality condition.

SAT-622 Rhabdomyolysis: A Rare Initial Presentation of Hypothyroidism

Introduction: Hypothyroidism is associated with a spectrum of musculoskeletal abnormalities as thyroid hormone signaling plays an integral role in skeletal muscle development and contractility. Mild to moderate CK elevation is present in majority of patients with symptomatic hypothyroidism. Overt rhabdomyolysis leading to acute kidney injury as a presentation of undiagnosed hypothyroidism is very rare. We present one such case. Case Description: 47-year-old African American woman with past medical history of non-insulin dependent diabetes and hypertension presented with myalgias and generalized edema in bilateral upper and lower extremities for the past 2 months. Outpatient labs revealed a Creatinine Kinase (CK) level of more than 10,000 U/L and an elevated creatinine level at 2 mg/dL. There was no history of trauma, immobilization, abnormal body movements, new drug use or recent fevers. At presentation, vital signs were stable. Physical examination showed non-pitting edema in bilateral upper and lower extremities. Initial work up revealed a creatinine of 2.15 mg/dL and CK level of 9173 U/L. Serum electrolytes were normal. Urine tested negative for myoglobin. Chest X ray and EKG were normal. Further testing revealed a TSH level of 148.7 mcIU/ml with T3 of <0.40 ng/dl and an undetectable T4 level. A diagnosis of primary hypothyroidism with rhabdomyolysis leading to acute kidney injury was made. She was treated with aggressive fluid resuscitation. She was also started on thyroid hormone supplementation with oral Levothyroxine 200 mcg/day. After initiation of treatment, the Creatinine levels trended down to 1.5 mg/dl. The CK levels trended down to 3600 U/L in 6 days after which she was discharged from the hospital. The patient was followed as an outpatient with gradual reduction of the CK levels over months. CK levels after 1 year were 154 U/L. The patient was continued on supplemental thyroid therapy. Discussion: Rhabdomyolysis is breakdown of muscle cells and release of muscle enzymes like Creatinine Kinase, electrolytes and myoglobin into the circulation. Among the various causes of Rhabdomyolysis, the most common are crush injuries, immobilization, seizures, heat stroke, sepsis and drugs like Statins, Colchicine and toxins like alcohol. Endocrinopathies like Hypothyroidism, Hyperthyroidism, Pheochromocytoma and Diabetes Ketoacidosis have been associated with rhabdomyolysis, but they tend to get ignored due to a lower incidence. Hypothyroidism is associated with elevation in CK levels in about 57-90% patients but the level of CK elevation is only mild, less than 10 times the upper limit of normal. Our case describes an uncommon initial presentation of hypothyroidism leading to overt rhabdomyolysis and acute kidney injury. It emphasizes the importance of checking a thyroid profile in a patient with acute elevation in muscle enzymes without an identifiable trigger.

Tilting the balance: hemidiaphragm paralysis leading to right to left cardiac shunt

Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. ^{1 2} It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Informed decision making (IDM) for prostate cancer (PCa) screening in a high-risk population

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Background: PCa incidence and mortality in African Americans (AA) is higher than in Caucasians. Health-education programs and culturally appropriate outreach to high-risk groups in accordance with American Cancer Society IDM guidelines can reduce disparities. Data show that it is hard to provide comprehensive unbiased education about screening to patients (pts). This study aims to examine whether IDM guidelines in a large high risk group setting can improve knowledge on PCa and screening decision, and whether such education program is overall beneficial to pts. Methods: Pts were included in one-day outreach event and were given a 15-question pre and post- test focused on standard informative educational PowerPoint and then were offered screening (PSA + DRE). Components of IDM were reviewed during this educational intervention. Demographics and family history was collected and UCSF 10-year mortality index was assessed to help IDM. Pre- and post- test number of correct answers were compared (Wilcoxon signed rank); pts were surveyed on their opinion on the program. The decision regarding screening after the intervention was tracked as well as the % of PCa diagnosed. Pts were tracked via an established navigation system to ensure follow up care. Results: 106 pts were included in the current analysis. Median number of correct answers at pre and post test was 8 and 11 (p < 0.001). Overall, 86% responded that they wanted screening. Of those, 92% were AA and 21% had family history of PCa; 21 pts had PSA only, 60 had PSA + DRE. 13 pts (16%) had abnormal PSA per NCCN guidelines, 5 (8%) had abnormal DRE. 5 PCa were biopsy-diagnosed, 4 had abnormal DRE + PSA; 1 had only abnormal DRE. Overall, 82% pts favored IDM before screening, 18% would prefer screening without IDM. 75% of all pts found the information “very helpful” in decision-making (within a 5-point Likert scale). Conclusions: Our education-based IDM led to significant improvement in knowledge about PCa screening. Most pts preferred education prior to screening. Our approach paired with the use of navigation program is feasible and was positively received by a large high risk group. Project is ongoing with more pts and follow up, and further validation is pending. Clinical trial information: NCT02419846.

Evaluation of prognostic factors in upper tract urothelial carcinoma (UTUC)

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Background: UTUC is relatively rare (5-10% of UC). Limited data on prognostic factors is available. Methods: A retrospective study of UTUC patients (pts) who had surgery (1995-2014) at Cleveland Clinic (n = 454) was conducted. Univariable (UVA) and multivariable (MVA) analysis (proportional hazards) with a stepwise selection algorithm (p = .10 and .05, as criteria for entry and retention in the model) was used to identify independent predictors of recurrence-free survival (RFS) and overall survival (OS). Results: 192 pts with invasive high grade UTUC were identified; median age at resection was 72; 69% men. 72% of pts had laparoscopic and 17% open nephrouretectomy, 23% had +ve margins (including bladder/ureter cuff), 22% had multifocal tumor. Median tumor size 3.5 cm (0.2-12); 70% had tumors < 5 cm; 65% pT3, 8% pT4 stage; among pts with lymph node (LN) dissection, 25% had +ve LN. All but 3 pts (2 sarcomatoid, 1 small cell) had primarily UC; 28% mixed UC histology; 40% CIS, 54% confirmed lymphovascular invasion (LVI); 10 neoadjuvant, 14 confirmed adjuvant therapy). Among 116 pts with RFS data available 59% had disease recurrence; 8% died with no known recurrence. Estimated median RFS was 13.1 months (m) (95%CI 8.6-18.6). In UVA, age, positive margins, tumor size, smoking history, pT stage, LVI, primary site impacted RFS. In MVA, margin status (p = .04), age (p = .04), pT stage (p = .05) were independently associated with RFS. Among 175 pts with OS data available, 38% died with estimated median OS 44.6 m (95%CI 24.1-107.4); median follow-up was 13.8 m (0.1-185.7) in pts alive at last follow up. In UVA, LVI, tumor size, age, pT stage, tumor location, ECOG PS impacted OS. In MVA, tumor size (p = .002), CIS (p = .004), tumor location (p = .04), LVI (p = .04) independently predicted OS. Using these factors, 3 prognostic groups were identified for each outcome (see table). Conclusions: Clinic-pathological parameters can be prognostic in UTUC; further validation is needed. [Table: see text]

Development of an adhesive surgical ward round checklist: a technique to improve patient safety

Checklists have been shown to improve patient outcomes. Checklist use is seen in the pre-operative to post-operative phases of the patient pathway. An adhesive checklist was developed for ward rounds due to the positive impact it could have on improving patient safety. Over an eight day period data were collected from five consultant-led teams that were randomly selected from the surgical department and divided into sticker groups and control groups. Across the board percentage adherence to the Good Surgical Practice Guidelines (GSPG) was markedly higher in the sticker study group, 1186 (91%) in comparison with the control group 718 (55%). There was significant improvement of documentation across all areas measured. An adhesive checklist for ward round note taking is a simple and cost-effective way to improve documentation, communication, hand-over, and patient safety. Successfully implemented in a tertiary level centre in Dublin, Ireland it is easily transferable to other surgical departments globally.

Cost analysis of an integrated care model in the management of acute exacerbations of chronic obstructive pulmonary disease

Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9—3.2). Cost per patient in the integrated care group was £1653 (95% CI, £1521—1802) compared with £2256 (95% CI, £2126— 2407) in the hospital group. The integrated care group resulted in cost saving of approximately £600 (P < 0.001) per patient. This integrated care model for the management of patients with AECOPD offered cost savings of £600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.

Bilateral responses of upper limb muscles to transcranial magnetic stimulation in human subjects

Anatomical and behavioural work on primates has shown bilateral innervation of axial and proximal limb muscles, and contralateral control of distal limb muscles. The following study examined if a clear boundary exists between the distal and proximal upper limb muscles that are controlled contralaterally or bilaterally. The right motor cortical area representing the upper limb was stimulated, while surface EMG was recorded bilaterally from various upper limb muscles during rest and phasic voluntary contractions. Peak-to-peak amplitude of motor evoked potential (MEP) was measured for each muscle on both sides. The ratio R = (ipsilateral MEP: contralateral MEP) was calculated for seven pairs of muscles. For each of the seven pairs, R was less than 1.0, implying that for each muscle and subject, the contralateral control is stronger. The boundary where R changed from almost zero to a clearly measurable magnitude depended on the subject. Ipsilateral MEPs from trapezius and pectoralis could be recorded with a small background contraction from almost all subjects; on the other hand, in deltoid and biceps brachii, ipsilateral MEPs were observed only with bimanual phasic contractions. The forearm and hand muscles, in general, did not show any ipsilateral MEPs. Major differences between subjects lay in the presence or the absence of ipsilateral MEPs in biceps brachii and deltoid, without defining a sharp boundary between proximal and distal muscles.

Interactions of bacterial cationic peptide antibiotics with outer and cytoplasmic membranes of Pseudomonas aeruginosa

Polymyxins B and E1 and gramicidin S are bacterium-derived cationic antimicrobial peptides. The polymyxins were more potent than gramicidin S against Pseudomonas aeruginosa, with MICs of 0.125 to 0. 25 and 8 microg/ml, respectively. These peptides differed in their affinities for binding to lipopolysaccharide, but all were able to permeabilize the outer membrane of wild-type P. aeruginosa PAO1 strain H103, suggesting differences in their mechanisms of self-promoted uptake. Gramicidin S caused rapid depolarization of the bacterial cytoplasmic membrane at concentrations at which no killing was observed within 30 min, whereas, conversely, the concentrations of the polymyxins that resulted in rapid killing resulted in minimal depolarization. These data indicate that the depolarization of the cytoplasmic membrane by these peptides did not correlate with bacterial cell lethality.

Immunological cross-reactivity between salivary gland proteins of Hyalomma anatolicum anatolicum and Boophilus microplus ticks

Immunological cross-reactivity was established between salivary gland extract antigens of Hyalomma anatolicum anatolicum (H.a.a) and Boophilus microplus (B.m.), using native-polyacrylamide gel electrophoresis (native-PAGE), immunoblotting, DOT-enzyme immunoassay (DOT-EIA) and in vivo intra-dermal skin test revealing immediate type hypersensitivity swelling reaction. Native-PAGE revealed six proteins in common of molecular weights of 60, 66, 148, 264, 300 and > 300 kDa in the salivary gland extract (SGE) of both the ticks. Four additional bands of molecular weights of 56, 64, 120 and 220 kDa were present in H.a.a. but absent in B.m. Immunoblot assay of native-PAGE transblotted proteins of H.a.a., using mice anti-H.a.a. SGE and anti-B.m. SGE immune serum revealed a common protein of 66 kDa. In DOT-EIA, anti-H.a.a. or anti-B.m. SGE immune serum gave similar antibody titres against the SGE antigens of either tick species. Intradermal inoculation of the SGE antigens of either species on cross-bred calves (Bos indicus x Bos taurus) immunized to H.a.a. or B.m. ticks produced a strong, immediately hypersensitivity skin swelling reaction.

The effect of the orally active platelet-activating factor antagonist WEB 2086 in the treatment of asthma

Platelet-activating factor (PAF) may be a major mediator of asthma and bronchial hyperreactivity through its many proinflammatory actions. Specific antagonism of PAF might offer an alternative anti-inflammatory treatment to inhaled corticosteroids. To test this, we have studied the effect of an orally active PAF antagonist, WEB 2086, on the inhaled steroid requirements of symptomatic atopic asthmatics in a double-blind randomized placebo-controlled parallel group study. The inhaled corticosteroid dose required for symptomatic control of asthma was established and further steroid reduction was attempted after treatment with WEB 2086 40 mg three times daily for 12 wk. Of 106 patients recruited, 68 entered the treatment phase and 65 completed 6 wk of treatment. The mean daily corticosteroid dose (SE) at study entry was 1,257 (75) micrograms which was reduced by 323 (66) micrograms during the run-in period without loss of symptomatic control. A further 416 (57) micrograms reduction in inhaled corticosteroid dosage was possible during the treatment phase but this was almost identical in the WEB 2086 and placebo-treated groups, amounting to 353 (92) and 481 (65) micrograms/day respectively (not significant [NS]). Rate of relapse following corticosteroid reduction was a continuous variable and relapse occurred at different times depending on the variable used to define it. Time to relapse measured by an increase in symptoms correlated with disease duration (r = 0.41, p < 0.01) and with the dose of inhaled corticosteroid at study entry (r = 0.36, p < 0.01) but no other measured variable predicted the time to relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Double-blind trial of the use of transfer factor in the treatment of Crohn's disease

We have undertaken a double-blind controlled trial of the use of transfer factor in Crohn's disease. Thirty-three patients with known Crohn's disease completed the trial in which half the patients had three injections of transfer factor and the other half were given saline. After six months there was no significant difference in the clinical condition of either of the two groups compared with before receiving treatment. There was also no difference in their in vitro lymphocyte function, although a number of patients exhibited altered responsiveness to skin testing with tuberculin or streptokinase/streptodornase. A signficant fall on Crohn's disease activity index score occurred over the initial 'acclimatising period' before the trial was started, probably related to overcoming initial introspection and the placebo effect of being part of a trial.