Sonography Research Articles

Predictive Value of Diaphragm and Lung Ultrasonography for Weaning Failure in Critically Ill Patients with Acute Respiratory Failure Due to COVID-19 Pneumonia.

This study analyzed weaning characteristics and assessed the association of clinical and ultrasonographic indices-maximum inspiratory pressure (MIP), rapid shallow breathing index (RSBI), peak flow expiratory (PFE), diaphragm-thickening fraction (DTF), diaphragm thickness (DT), diaphragm excursion (DE), diaphragm-RSBI (D-RSBI), and lung ultrasound (LUS) patterns-with weaning failure. This retrospective cohort study included critically ill COVID-19 patients aged 18 and older who had been on invasive mechanical ventilation for at least 48 h and undergoing weaning. Exclusion criteria included absence of ultrasound assessments, neuromuscular diseases, and chronic cardio-respiratory dysfunction. Among 61 patients, 44.3% experienced weaning failure, 27.9% failed the spontaneous breathing trial (SBT), 16.4% were re-intubated within 48 h, and 28% required tracheostomy. Weaning failure was associated with prolonged ventilation (29 vs. 7 days, p < 0.001), extended oxygen therapy, longer ICU stays, and higher ICU mortality. These patients had higher pressure support, lower oxygenation levels, a higher RSBI, and a lower MIP. While PEF, DTF, DE, and D-RSBI showed no significant differences, both right and left diaphragm thicknesses and the inspiratory thickness of the left diaphragm were reduced in failure cases. LUS scores were significantly higher before and after SBT in the failure group. Bivariate analysis identified RSBI [OR = 1.04 (95% CI = 1.01-1.07), p = 0.010], MIP [OR = 0.92 (95% CI = 0.86-0.99), p = 0.018], and LUS [OR = 1.15 (95% CI = 0.98-1.35), p = 0.025] as predictors of weaning failure; however, these associations were not confirmed in multivariate analysis. Ultrasound provides supplementary information during weaning, but no definitive association between ultrasound indices and weaning failure was confirmed in this study.

Current approaches to prenatal imaging of lung malformations: a review

INTRODUCTION: Congenital lung malformations are result of developmental disorders at any stage of organ formation. Manifestations of these changes vary significantly: from minimal in size to large space-occupying lesion of the lung, which can cause fetal death or severe postnatal respiratory disorders. In proper time and accurate prenatal diagnosis of lung development abnormalities is one of the fundamental factors determining management of pregnancy and prognosis.OBJECTIVE: To demonstrate the most typical features of a wide range of congenital lung anomalies by ultrasound and MRI.MATERIALS AND METHODS: The literature search was performed in open Russian and English databases Medline, PubMed, Web of Science, RSCI, eLIBRARY using keywords and phrases: «prenatal diagnosis», «fetal MRI», «ultrasound diagnostics», «сongenital lung malformations».RESULTS: Based on literature data and our own experience in the use of ultrasound and MRI in diagnosis of сongenital lung malformations, the main signs of normal development and the most specific types of lung anomalies are described. Algorithm for diagnostic search for congenital lung malformations is presented.CONCLUSION: Ultrasound is the main method for diagnosing congenital lung anomalies. Fetal MRI is used to clarify the nature and extent of changes, a more detailed assessment of adjacent organs, also to determine Multiple congenital anomalies. Understanding the characteristics of semiotics of lung malformations and the main signs of these anomalies is a fundamental criterion for prenatal counseling, as well as peri- and postnatal management of this category of patients.

Diagnostic efficacy and value of ultrasound in children's scrotal testicular torsion: A retrospective analysis.

The purpose of this study is to explore the diagnostic efficacy and value of ultrasound detection for testicular torsion in children with scrotal and testicular diseases. A total of 120 children with acute scrotal swelling and pain who were treated in our hospital from August 2017 to August 2022 were selected for preliminary diagnosis through color Doppler ultrasound diagnostic instrument examination. The final diagnosis was made through surgical or conservative treatment. At the same time, 40 children with acute epididymitis during the same period were selected as the control group, and the clinical treatment of patients with testicular diseases was retrospectively analyzed. A total of 120 children were diagnosed with testicular torsion disease, with 57 cases affecting the left testicle and 63 cases affecting the right testicle. Ultrasound examinations revealed no blood flow signal in 78 cases, a significant reduction in blood flow in 38 cases, and no change in 4 cases. Among the pediatric patients who underwent manual reduction, 79 cases had a favorable prognosis. Surgical reduction was performed in 41 cases, with 35 cases successfully treated and 6 cases resulting in testicular removal. Follow-up examinations conducted 6 months to 1 year postoperatively showed testicular atrophy in 4 out of 35 cases with preserved testicles, while the 6 cases that underwent testicular resection had good outcomes. The non-active subgroup had a longer disease course and a greater degree of torsion (P < .05). There was no statistically significant difference in testicular volume and the ratio of healthy testicular volume between the 2 groups (P > .05). The sensitivity of ultrasound diagnosis was 95.24% (73/77), specificity was 78.57% (34/43), and accuracy was 89.29% (107/120). Ultrasound can effectively diagnose testicular torsion and evaluate the success rate of testicular reduction. Early treatment of patients with testicular torsion leads to better efficacy and higher survival rates.

Nosological Pattern of Diseases Accompanied by Chronic Cough in Dogs

Introduction. A practicing veterinarian usually faces difficulties in both diagnosing and treating coughing in dogs. The unsolved problem in diagnosing entails doubts in the efficacy of the prescribed therapy. This is especially relevant for small dog breeds of middle and old age that often suffer from the chronic respiratory diseases and mitral insufficiency due to endocardiosis, and each of these diseases can lead to chronic cough. The aim of the research is to reveal the nosological pattern of the diseases accompanied by chronic cough in dogs.Materials and Methods. The research was based on the analysis of the medical records of 145 dogs with chronic cough that have attended to the network of veterinary clinics “Vita” (Rostov region) in the period from September 1, 2021 to July 31, 2024. The research was carried out using the following equipment: Karl Storz video bronchoscope (PAL colour system, working channel 2.3 mm, gaze direction 0°, aperture angle 120°, up/down deviation 180°/100°, depth of field 3–50 mm, working length 61 cm, outer diameter 6.2 mm); premium ultrasound scanner with improved image quality on the ZST+Mindray Vetus 9 platform; Maxivet 400 veterinary X-ray digital DR system; Poli-Spectrum–8/B computerassisted electrocardiograph; automatic hematology analyzer Idexx ProCyte Dx; automatic biochemistry analyzer Idexx Catalyst One; digital microscope Celestron.Results. The conducted research allowed us to find out the main causes of coughing in dogs. The most common cause of chronic cough found in these animals was chronic bronchitis, including that occurring simultaneously with the collapse of the upper respiratory tract. The rarest revealed cause of chronic cough was endocardiosis.Discussion and Conclusion. Coughing in dogs is not a characteristic sign of endocardiosis: even when the disease was clinically evident, coughing was observed only in the cases of lung congestion and interstitial pulmonary edema. As a rule, dogs with endocardiosis that have a pronounced loud cough intensifying after exertion, have a concomitant disease of the upper respiratory tract. Coughing in dogs with endocardiosis and upper respiratory tract lesion does not go away upon getting merely a specific endocardiosis treatment.

Causes and Diagnostic Significance of Coughing in Dogs with Endocardiosis

Introduction. Endocardiosis is the most widespread acquired cardiac disease in small dog breeds, characterised by the valvular degeneration leading to mitral insufficiency. Progression of mitral regurgitation leads to cardiac remodeling, increased left ventricular filling pressures, pulmonary hypertension and, eventually, myocardial dysfunction. Decreased exercise tolerance, dyspnea, anorexia, and coughing are the most often reported signs in dogs with endocardiosis. Coughing is often reported as the primary clinical sign of congestive heart failure in dogs with endocardiosis. The concomitant respiratory tract disease and compression of the left mainstem bronchus by the giant left atrium have also been suggested as the potential causes of coughing in these patients. However, the absence of relief from cough in dogs with endocardiosis when treated with calcium sensitizers and the registered improvement in systolic cardiac function makes doubtful the cardiogenic nature of coughing in endocardiosis. In other words, the clinical and diagnostic significance of coughing in dogs with endocardiosis has not been sufficiently studied. The aim of the present research is to determine the frequency of cough incidence in dogs with endocardiosis and to establish the pathognomonic nature of this symptom in endocardiosis, its clinical significance.Materials and Methods. The medical records of 49 dogs that have attended to the veterinary clinics of the “Vita” network (Rostov region) for cardiological examination in the period from September 1, 2021 to July 31, 2024 were analysed. The research was carried out using the following equipment: premium ultrasound scanner with improved image quality on the ZST+ Mindray Vetus 9 platform, Maxivet 400 veterinary X-ray digital DR system, and Poli-Spectrum–8/V computerassisted electrocardiograph.Results. The research allowed us to find out the following: although the cardiomegaly and the increase in the size of the left ventricle in endocardiosis can aggravate and intensify the clinical manifestation of coughing in dogs with degenerative diseases of the upper respiratory tract, they are not the necessary condition for the occurrence of coughing. Coughing in dogs with endocardiosis should be considered as a clinical sign of the concomitant inflammatory or degenerative disease of the upper respiratory tract, which should be taken into account in therapy and in the attempt to improve the quality of life of these animals.Discussion and Conclusion. We have found that only 57% of the dogs with clinically evident endocardiosis suffer from coughing, whereas it does not have the uniform nature. In dogs with cardiogenic pulmonary edema, a cough is not loud, is usually acute and is associated with the flow of fluid into the medium and large-sized bronchi. The chronic loud, hoarse cough, intensifying in the morning, is typical for dogs with endocardiosis and chronic bronchitis: these animals at the same time have the non-specific inflammatory lesion of the bronchial tree and lesion of the mitral valves. Most severe coughing, with the characteristic loud sound, is observed in dogs suffering from the elements of the upper respiratory tract collapse and cardiomegaly due to endocardiosis.

Nuts and bolts of lung ultrasound: utility, scanning techniques, protocols, and findings in common pathologies.

Point of Care ultrasound (POCUS) of the lungs, also known as lung ultrasound (LUS), has emerged as a technique that allows for the diagnosis of many respiratory pathologies with greater accuracy and speed compared to conventional techniques such as chest x-ray and auscultation. The goal of this narrative review is to provide a simple and practical approach to LUS for critical care, pulmonary, and anesthesia providers, as well as respiratory therapists and other health care providers to be able to implement this technique into their clinical practice. In this review, we will discuss the basic physics of LUS, provide a hands-on scanning technique, describe LUS findings seen in normal and pathological conditions (such as mainstem intubation, pneumothorax, atelectasis, pneumonia, aspiration, COPD exacerbation, cardiogenic pulmonary edema, ARDS, and pleural effusion) and also review the training necessary to achieve competence in LUS.

Prognostic Role of Specific KRAS Mutations Detected in Aspiration and Liquid Biopsies from Patients with Pancreatic Cancer

Background/Objectives: Although the overall survival prognosis of patients in advanced stages of pancreatic ductal adenocarcinoma (PDAC) is poor, typically ranging from days to months from diagnosis, there are rare cases of patients remaining in therapy for longer periods of time. Early estimations of survival prognosis would allow rational decisions on complex therapy interventions, including radical surgery and robust systemic therapy regimens. Understandably, there is great interest in finding prognostic markers that can be used for patient stratification. We determined the role of various KRAS mutations in the prognosis of PDAC patients using biopsy samples and circulating tumor DNA. Methods: A total of 118 patients with PDAC, clinically confirmed by endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNB), were included in the study. DNA was extracted from cytological slides following a standard cytology evaluation to ensure adequacy (viability and quantity) and to mark the tumor cell fraction. Circulating tumor DNA (ctDNA) was extracted from plasma samples of 45 patients in stage IV of the disease. KRAS mutations in exons 12 and 13 were detected by denaturing capillary electrophoresis (DCE), revealing a minute presence of mutation-specific heteroduplexes. Kaplan–Meier survival curves were calculated for individual KRAS mutation types. Results:KRAS mutations were detected in 90% of tissue (106/118) and 44% of plasma (20/45) samples. All mutations were localized at exon 2, codon 12, with G12D (GGT &gt; GAT) being the most frequent at 44% (47/106) and 65% (13/20), followed by other types including G12V (GGT &gt; GTT) at 31% (33/106) and 10% (2/20), G12R (GGT &gt; CGT) at 17% (18/106) and 10% (2/20), G12C (GGT/TGT) at 5% (5/106) and 0% (0/20) and G12S (GGT/AGT) at 1% (1/106) and 5% (1/20) in tissue and plasma samples, respectively. Two patients had two mutations simultaneously (G12V + G12S and G12D + G12S) in both types of samples (2%, 2/106 and 10%, 2/20 in tissue and plasma samples, respectively). The median survival of patients with the G12D mutation in tissues was less than half that of other patients (median survival 101 days, 95% CI: 80–600 vs. 228 days, 95% CI: 184–602), with a statistically significant overall difference in survival (p = 0.0080, log-rank test), and furthermore it was less than that of all combined patients with other mutation types (101 days, 95% CI: 80–600 vs. 210 days, 95% CI: 161–602, p = 0.0166). For plasma samples, the survival of patients with this mutation was six times shorter than that of patients without the G12D mutation (27 days, 95% CI: 8–334 vs. 161 days, 95% CI: 107–536, p = 0.0200). In contrast, patients with detected KRAS G12R in the tissue survived nearly twice as long as other patients in the aggregate (286 days, 95% CI: 70–602 vs. 162 days, 95% CI: 122–600, p = 0.0374) or patients with other KRAS mutations (286 days, 95% CI: 70–602 vs. 137 days, 95% CI: 107–600, p = 0.0257). Conclusions: Differentiation of specific KRAS mutations in EUS-FNB and ctDNA (above all, the crucial G12D and G12R) is feasible in routine management of PDAC patients and imperative for assessment of prognosis.

Lung ultrasound assessment of atelectasis following different anesthesia induction techniques in pediatric patients: a propensity score-matched, observational study

IntroductionAtelectasis is a well-documented complication in pediatric patients undergoing general anesthesia. Its incidence varies significantly based on surgical procedures and anesthesia techniques. Inhalation induction, commonly used to avoid the discomfort of venipuncture, is suspected to cause higher rates of respiratory complications, including atelectasis, compared to intravenous induction. This study aimed to evaluate the impact of inhalation versus intravenous anesthesia induction on atelectasis formation in pediatric patients, as assessed by lung ultrasound (LUS).MethodsThis propensity score-matched observational study was conducted at a tertiary pediatric hospital in Milan, Italy. Inclusion criteria were children ≤ 18 years undergoing elective surgery with general anesthesia. Patients were divided into inhalation and intravenous induction groups. LUS was performed before and after anesthesia induction to assess lung aeration. The primary endpoint was the global LUS score post-induction, with secondary endpoints including the incidence and distribution of atelectasis.ResultsOf the 326 patients included, 65% underwent inhalation induction and 35% intravenous induction. The global LUS score was significantly higher in the inhalation group (12.0 vs. 4.0, p < 0.001). After propensity score matching (for age, presence of upper respiratory tract infection, duration of induction, and PEEP levels at induction), average treatment effect (ATE) of mask induction was 5.89 (95% CI, 3.21–8.58; p < 0.001) point on LUS global score and a coefficient of 0.35 (OR 1.41) for atelectasis.DiscussionInhalation induction is associated with a higher incidence of atelectasis in pediatric patients also when we adjusted for clinically relevant covariates.Trial registrationClinicalTrials.gov identifier: NCT06069414.

7452 A Diagnostically Challenging Case of Hyperandrogenism in Postmenopausal Woman

Abstract Disclosure: M.S. Hossain: None. S. Hossain: None. B. Gautam: None. H. liao: None. S.C. Kumar: None. D.S. Rosenthal: None. Background: The diagnosis of new-onset severe hyperandrogenism in postmenopausal women is rarely encountered, posing a unique challenge for clinicians. Ovarian hyperthecosis and androgen-secreting tumors are the usual suspects in post menopause. In our case ovarian hyperthecosis is the primary consideration but elevated 17-OH Progesterone (17-OHP) introduces the potential co-existence of Non classical congenial adrenal hyperplasia (NCCAH) or rare instances of Sertoli-Leydig Cell Tumor (SLCT). Case Presentation: A 70 years old female, with no past medical history, referred to the Endocrinology clinic for significantly elevated testosterone level. She reported excessive hair growth in various areas of her body since 2022, which required shaving almost every day. She also reported male pattern hair loss and weight loss of 15 lbs over the last three months. She denied headache, vision changes, deepening of voice, history of fertility problems and use of exogenous testosterone. Her vital sign were normal. On examination, she had clitoromegaly, terminal hair growth on her upper lip and chin, breast atrophy, male pattern baldness, but no cushingoid or acromegaly features. Blood tests showed significantly elevated total testosterone: 1422 ng/dl (2-45); free testosterone: 147.9 pg/ml (0.2-3.7) and Estradiol: 64 pg/ml (Postmenopausal &amp;lt;31) with low LH: 7.6 mIU/ml (Postmenopausal 10.0-54.7) and FSH: 22.2 mIU/mL (Postmenopausal 23-116). Her serum ACTH, DHEA Sulfate, 11-deoxycortisol, 17 OH pregnenolone, TSH, Free T4, prolactin, IGF-1 were normal while her 17-OHP: 396 ng/dl (&amp;lt;45 ng/dl) was significantly elevated. An ACTH stimulation test showed 17-OHP level of 734 ng/dl at 30 minutes and 901 ng/dl at 1 hour. Pelvic ultrasonography: right ovary of 2.3 x 1.6 x 1.9 cm and the left ovary of 3.1 x 1.8 x 3.0 cm. MRI showed normal adrenal glands but a prominent left ovary. Patient was referred to the Obstetrics department to undergo bilateral oophorectomy for the definitive diagnosis and treatment. Discussion: The current ACTH stimulation test for non-classical congenital adrenal hyperplasia is validated for premenopausal women but lacks standardization in post-menopausal state. In our case, distinguishing the source of elevated 17-OHP between adrenal (NCCAH) and ovarian (SLCT) was difficult. Unexpected asymmetry in ovarian size observed in our case further complicates the scenario, contrasting with the typical symmetrical enlargement seen in ovarian hyperthecosis. Pending surgical pathology will further guide the management. This case highlights the complexity of diagnosing hyperandrogenism in postmenopausal women, emphasizing the significance of thoroughly exploring differential diagnoses and meticulously analyzing laboratory results. Presentation: 6/2/2024

7709 Ovotesticular Difference of Sex Development: Prognostic Evaluation, Sex Assignment, and Ethics

Abstract Disclosure: X. Xu: None. Y. Lin: None. B. Shivanna: None. A. Lee: None. J.C. Hakim: None. D.G. Mann: None. L.M. Noll: None. P. Georgiadis: None. S.K. Gunn: None. L.P. Karaviti: None. Background: Our case provides the identification and management of a newborn baby with ovotesticular syndrome, which was formerly known as true hermaphroditism. The term was classically derived from Greek mythology in which the deity 'Hermaphroditus', merging with the nymph Salamis, embodied both male and female attributes. The term 'true hermaphroditism' is now avoided due to its stigmatizing connotations. Ovotesticular difference of sex development (DSD) is an exceedingly rare condition, occurring in fewer than 1 in 20,000 births. This condition involves the coexistence of functional ovarian and testicular tissue within one individual, presenting a challenge in sex assignment due to unpredictable gender development. Clinical Case: This is a single case of the presence of ovarian and testicular differentiation on one side and a transitional zone of mixed pattern. Prenatal genetic testing consistent 46,XX karyotype. Initial ultrasound at the outside hospital revealed a uterus and right testicle. The baby exhibited Prader stage 4 genitalia, with a palpable gonad in the right labioscrotal area and the left gonad not palpable. Prophylactic hydrocortisone was started due to concerns regarding NR5A1/SF1 mutation. Further evaluations, including genetic tests, hormonal assessments, urinalysis and kidney ultrasound for the WT1 mutation, and scrotal and pelvic ultrasounds, were conducted. The high-dose ACTH stimulation test ruled out adrenal insufficiency. The testosterone level was in the male range, and the HCG stimulation test further confirmed functioning Leydig cells. The postnatal karyotype was 46,XX, and chromosome microarray analysis showed no abnormalities. Our approach to this case was multidisciplinary, including our endocrine experts, urologist, gynecologist, ethicist, and psychologist. We discussed the fluidity of sex assignment and addressed the degree of virilization, nature of the gonadal tissue, and emphasized the necessity of regular clinical follow-up. Our main concern was to educate the parents and protect the choices of the child. In this case, the child assumed a male sex assignment, as a result of the decision-making process between our team and the parents. In this context we did emphasize the fluidity of sex assignment. Clinical Lesson: Long-term outcomes for ovotesticular DSD remain understudied. Existing reports highlight varying rates of gender dysphoria, sexual function, and psychological well-being. Our approach to managing ovotesticular DSD involved a framework emphasizing ethical considerations and parental involvement. We advocated for and practiced a shared decision-making model involving healthcare providers, parents, and ultimately the patient. Presentation: 6/3/2024

12465 Unraveling The Enigma: A Multifaceted Presentation Of Hormonal Dysregulation In A 37-year-old Woman

Abstract Disclosure: S.Y. Rizvi: None. N. Ahmad: None. Title: Unraveling the Enigma: A Multifaceted Presentation of Hormonal Dysregulation in a 37-Year-Old Woman Background: Leydig cell tumors (LCTs) are rare gonadal tumors, arising from the interstitial cells of the testis or, less commonly, the ovary, 0.1%. These tumors are known for their potential to produce androgens, leading to virilization symptoms such as hirsutism. While LCTs are typically benign, they can occasionally exhibit malignant features. Accurate diagnosis and appropriate management are crucial to prevent complications and ensure favorable outcomes. Clinical Case: A 37-year-old, G3P3A0 woman, presented to our endocrinology clinic for a follow-up visit following the removal of a malignant thyroid nodule. During the visit, her endocrinologist noted elevated testosterone levels and worsening hirsutism. She reported mild abdominal pressure but denied other symptoms. She also complained of pain in the lower abdomen, although physical examination findings were limited due to type II obesity. Diagnostic investigations revealed a history of imaging studies, including CT scans and pelvic ultrasounds, demonstrating various findings such as a fibroid uterus, ovarian abnormalities, and a heterogeneous mass in the left adnexa. Laboratory evaluations over time showed fluctuations in androgen levels, with notable values including DHEA-sulfate (137.5 ug/dL), total testosterone (309.6 NG/dL), and free testosterone (12.85 NG/dL). Tumor markers, including CA 19-9= 16 U/mL, CA 125= 23.3 U/mL, CEA = 1.7 NG/mL, and HCG, were unremarkable. Gynae/Oncology was consulted, and she underwent surgical exploration with laparoscopic left oophorectomy. It revealed a Leydig cell tumor without overt malignant features, as confirmed by histopathological examination and immunohistochemical analysis. Her testosterone improved since oophorectomy. Patient undergoes frequent post-op follow up of her testosterone, free+total lc/MS to monitor for hyperandrogenism. Conclusion: This case highlights the importance of considering Leydig cell tumors in the differential diagnosis of hirsutism, particularly in the presence of elevated androgen levels. Multidisciplinary collaboration involving endocrinologists, gynecologists, oncologists, radiologists, and pathologists is essential for accurate diagnosis and optimal management. Surgical resection remains the cornerstone of treatment for Leydig cell tumors, with careful histopathological evaluation necessary to assess for potential malignancy. Long-term follow-up is warranted to monitor for recurrence or metastasis, although the prognosis for benign Leydig cell tumors is generally favorable. Patients with large body habitus may present challenges in physical examination, necessitating reliance on imaging and laboratory studies for diagnostic evaluation. Keywords: hirsutism, testosterone, ovary Presentation: 6/2/2024

7407 Normosmic Idiopathic Hypogonadotropic Hypogonadism in Women: A Case Report and Comprehensive Review

Abstract Disclosure: E.G. Bustamante: None. M. Sulehri: None. I. Patoli: None. A. Karunakaran: None. Normosmic Idiopathic Hypogonadotropic Hypogonadism (nIHH) in Women: A Case Report and Literature ReviewIntroduction: IHH is a rare genetic disorder affecting gonadotropic-releasing hormone (GnRH) production and/or action, resulting in diminished sex steroid levels. Characterized by the absence of spontaneous pubertal development. In women, it manifests with normal adrenarche but absent thelarche and menarche. Our case highlight a late diagnosis of IHH in a 34-year-old woman with primary amenorrhea. Case report: A 34 year old lady with a history of primary amenorrhea sought evaluation. At age 16, she underwent assessment for short stature and primary amenorrhea, denying anosmia, headache, visual disturbances. Evaluation revealed bone age concordant with chronological age and normal MRI Brain. Pelvic ultrasound (US) showed small premenarchal uterus and ovaries. She initiated oral contraceptive pills (OCP) and experienced regular menses. Seeking fertility assistance at age 24, a normal Hysterosalpingogram was followed by successful delivery of twins after ovarian stimulation. Post-delivery menses did not resume and OCP was not restarted. Family history revealed a sister with irregular periods requiring OCP.Subsequently workup at age 30 showed Estradiol 22 pg/ml, FSH/LH 4.1/2.3 mUI/mL; normal PRL, TFT, DHEAS, 17OHP. Repeat Pelvic US showed normal uterus, endometrial stripe normal at 0.24 cm and non-visualized ovaries. PCOS testing negative for hyperandrogenism. Progesterone challenge resulted in no withdrawal bleeding. Brain MRI demonstrated a 2.2 x 1.3 mm hypoenhancing ovoid mass in the pars Intermedia of the pituitary gland suggestive of pituitary microadenoma. Pituitary axis hormonal testing was normal. Karyotype revealed 46 XX (normal female). Genetic evaluation identified a pathogenic variant (p.R35C) in GNRH1 gene. Her final diagnosis: nIHH. Discussion HH is diagnosed in 5% of all women with primary amenorrhea and is divided into 2 major categories: Kallmann syndrome and nIHH. The majority of known causes of HH can be attributed to mutations in KAL1, FGFR1, or GNRHR. The p.R35C variant has been associated with autosomal dominant nIHH. Diagnosis involves clinical suspicious, low LH/FSH and sex steroid levels, normal hypothalamic–pituitary imaging, and exclusion of differentials.Treatment goal for female focus on regular breast and uterine development, as well as the capability to conceive. Use of hormonal replacement therapy and/or gonadotropins or pulsatile GnRH for ovarian stimulation are essential. ConclusionWhile IHH predominantly affects men, limited literature explores its manifestation in women and its impact on fertility. The identification of a GNRH1-related nIHH variant highlights the role of genetic testing in specific HH diagnoses. Failure to diagnose in adolescence may compromise women overall well-being Presentation: 6/1/2024

7235 Papillary Thyroid Carcinoma in a Hyperfunctioning Thyroid Nodule

Abstract Disclosure: J. Yang: None. P.V. Nadkarni: None. Background: The prevalence of malignancy in a hyperfunctioning or hot thyroid nodule is considered to be low. According to the 2015 American Thyroid Association Guidelines, no cytologic evaluation is routinely recommended for hyperfunctioning nodules since they are rarely associated with malignancy (1). We present a case of a 71-year-old female with a hot nodule containing papillary thyroid cancer. Clinical Case: A 71-year-old female with Type 1 diabetes mellitus and coronary artery disease on dual antiplatelet therapy was found to have a 1.5 cm firm, non-tender right-sided thyroid nodule on a routine physical exam. Laboratory tests demonstrated low TSH &amp;lt;0.01 (normal 0.36 - 3.74 m[IU]/L) and FT4 level elevated at 1.62 (normal 0.76 -1.46 ng/dL). She noticed palpitations and started on low dose Methimazole. Thyroid ultrasound results showed a 2.1 x 2.0 x 2.0 cm right inferior lobe thyroid nodule. This thyroid nodule appeared mixed cystic and solid, hypoechoic, not taller than wide, with ill-defined margins and peripheral calcifications (ACR TI-RADS risk category: TR4). Nuclear medicine thyroid uptake scan demonstrated focally increased activity in the right lower pole corresponding with her right inferior thyroid nodule seen on ultrasound. Remainder of the gland appeared suppressed. She was recommended for ultrasound-guided fine needle aspiration biopsy of her right inferior thyroid nodule, given concerning characteristics on ultrasound findings despite results consistent with a hot nodule. Timing of her antiplatelet therapy was coordinated with her cardiologist, and her biopsy procedure scheduled after she stopped dual antiplatelet therapy. Her FNA results showed clusters of follicular cells with nuclear and architectural atypia, suspicious for papillary thyroid carcinoma. She underwent right thyroid lobectomy. Surgical pathology revealed 2 foci of papillary thyroid carcinoma, follicular variant (2.0 cm, 0.1 cm) and confined to the thyroid. All regional lymph nodes were negative for tumor. Methimazole was discontinued post-operatively, and she started Levothyroxine suppression therapy. Discussion: We present a rare association of papillary thyroid carcinoma presenting as a hot thyroid nodule. Though uncommon, detection of a hyperfunctioning thyroid nodule does not exclude the possibility of thyroid carcinoma and warrants careful evaluation. Clinicians should retain a high index of suspicion particularly when ultrasonography demonstrates findings suspicious for malignancy and consider additional evaluation with fine needle aspiration. Reference: (1) Haugen BR, Alexander EK, Bible KC et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016 Jan;26(1):1-133. Presentation: 6/2/2024

6666 Asymptomatic Fasting Hypoglycemia After Sleeve Gastrectomy

Abstract Disclosure: K. Mitrollari: None. H.K. Deveaux: None. A. Gundeti: None. A.P. Calimag: None. T. Yasmeen: None. Introduction: Post-bariatric surgery hypoglycemia (PBSH), though previously considered rare, is increasingly recognized, occurring not only after Roux-en-Y gastric bypass (RYGB,) but also following various bariatric procedures. PBSH can manifest as postprandial or fasting hypoglycemia, requiring thorough investigation and prevention due to potential asymptomatic presentations that may lead to severe consequences, including coma and death. Case Report A 45-year-old female with a history of type 2 DM, ESRD on HD, gastric sleeve surgery, bilateral trans-metatarsal amputations, coronary artery disease, and congestive heart failure presented with bilateral lower extremity wounds. On admission her venous blood glucose was 71 mg/dL. Glycohemoglobin was 3.9% and fructosamine was 225 (205-285 umol/L). Her glycohemoglobin levels consistently remained below 6.4% status post sleeve gastrectomy off diabetes medications. Throughout admission, she experienced almost daily episodes of fasting asymptomatic hypoglycemia correlated with venous sample with lowest blood glucose reading 38 mg/dL. Initially, these episodes were attributed to NPO status for procedures or decreased PO intake. Her diet consisted of fast food brought by her family, which she reported was similar to her diet at home. Workup during a hypoglycemic episode (glucose 51 mg/dL,) revealed insulin 4 mUnits/L, proinsulin 7.1 pmol/L (&amp;lt;=7.2 pmol/L), C-peptide 25.7 ng/mL (0.8-3.9 ng/mL), and beta-hydroxybutyrate 0.5 mmol/L (0.0-0.3 mmol/L). Negative insulin antibodies and sulfonylurea panel, normal cortisol, and ACTH levels were noted. The patient was placed on a 10% dextrose infusion to avoid further episodes of hypoglycemia. However, she continued to experience hypoglycemia and was started on oral diazoxide. A CT pancreas with and without contrast was unremarkable, and endoscopic ultrasonography only revealed a 10 mm accessory spleen. The patient was discharged with counseling on glucose monitoring, dietary changes, and follow-up with endocrinology. Conclusion: PBSH should be considered as a differential diagnosis in patients with unexplained hypoglycemia and a history of bariatric surgery. PBSH mimics insulinoma or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS) with elevated insulin, proinsulin, C-peptide, and low beta-hydroxybutyrate during hypoglycemia, however NIPHS is exclusive to non-bariatric patients. Imaging is crucial to rule out insulinoma, and invasive tests such as endoscopic ultrasound aid diagnosis. PBSH is a diagnosis of exclusion; therefore, workup involves ruling out other causes of hypoglycemia. First-line treatment involves diet modification, with medications like diazoxide or acarbose considered if dietary changes prove insufficient. This case underscores the complexity of hypoglycemia, implicating bariatric surgery as a contributing factor. Presentation: 6/3/2024

8764 A Unique Case of Infertility in a Patient with NCCAH

Abstract Disclosure: M. Paravastu: None. R. Patel: None. Background: Non-Classic Congenital Adrenal Hyperplasia (NCCAH) in women often presents with hirsutism, acne, menstrual dysfunction, or infertility. Subfertility in patients with NCCAH can be attributed to menstrual disorders including oligomenorrhea or secondary amenorrhea. We report a unique case in which a patient with NCCAH with consistently normal menstrual cycles is experiencing infertility. Case Description: A 31 y/o female with no PMH was referred to our Endocrinology Clinic for evaluation of Infertility and elevated 17-Hydroxyprogesterone levels (17OHP). Patient has been having trouble conceiving for the past 2 years, no prior successful pregnancies. She started menstrual cycles at age 17, she reports having regular menstrual cycles. Prior to our evaluation, she was seen in Reproductive Endocrinology who completed hormonal and imaging evaluation. Elevated 17OHP: 286ng/dL. Rest of hormonal workup within normal range. Normal Pelvic Ultrasound. Hormonal workup was repeated in our clinic. 17OHP is elevated at 617.01ng/dL. Rest of lab work returned normal with DHEAS:218.9mcg/dL, TSH: 2.826mcUnits/mL, Free Testosterone: 5.4pg/mL, Prolactin:11.7ng/mL, Beta HCG: negative, LH: 13.5mUnits/mL, FSH: 5.3mUnits/mL, Estradiol 79pg/mL. Cosyntropin stimulation test was completed. Baseline AM 17OHP:469.78ng/dL, Baseline Cortisol: 17.9mcg/dL. 17OHP 30 minutes-post:1216.4ng/dL, Cortisol 30 minutes-post: 18.5mcg/dL. 17OHP 60 min-post: 1051ng/dL, Cortisol 60 minutes post:16.4 mcg/dL. Given Inconclusive Cosyntropin stimulation test results, Genetic Testing was recommended. Genetic testing returned positive for NCCAH, patient’s husband is not a carrier of this gene. She was started on Hydrocortisone therapy for treatment of infertility. Shortly after she started on hydrocortisone therapy, patient did successfully conceive, however the pregnancy later resulted in a miscarriage. Conclusion: Subfertility in patients in NCCAH is thought to be due to menstrual irregularities including oligomenorrhea or secondary amenorrhea. We report the first case of a woman with diagnosis of NCCAH who is experiencing infertility despite having normal menstrual cycles. Presentation: 6/1/2024

8229 Prevalence of Thyroid Cancer in Patients with Hashimotos Thyroiditis Presenting Concomitant Thyroid Nodular Disease

Abstract Disclosure: M.A. Alvarez Castillo: None. L. Sanchez Arriaga: None. A. Segovia Palomo: None. Introduction: Hashimoto's thyroiditis (HT) is the most frequent autoimmune thyroid disease and the main cause of goiter and hypothyroidism; it induces a process of aseptic autoimmune inflammation. Fibroinflammatory changes lead to the development of thyroid nodules (TN), additionally chronic inflammation is an important player in the development of cancer, although this association is controversial. The prevalence of thyroid cancer (TC) in patients with HT ranges from 0.61-58.4% (25.01%), being higher than in patients with TN without concomitant HT. Objective: To know the prevalence of malignancy in patients with HT who present thyroid nodular disease. Methodology: An observational, descriptive, retrospective, and longitudinal study was carried out. Patients with HT diagnosis were selected by measuring Ab TPO and/or Ab TG who presented an ultrasound diagnosis of TN and FNAB of the thyroid lesion had been performed. Descriptive statistics and linear regression were used. Results: 87 patients: 6 (6.9%) men and 81 (93.1%) women aged 47.9 (12.7) years. 4 (4.5%) required FNAB in 2 TN, for a total of 91 TN studied. 64% had a diagnosis of hypothyroidism and were taking LT4, TSH 4.40 (4.44) mUI/mL, FT4 1.00 (0.27) ng/dL. Mean Ab TPO was 794.7 ± 1354.6. Diagnosis time 19.5 (29.1) months. 39.6% the detection was made by the patient and 35.2% by the doctor. Major axis was 18.8 (12.1) mm. Ultrasound pattern of single TN 58.2% and multinodular 41.8%. Median TIRADS was 4, with a mode of 5. 81.3% reported Bethesda II and 18.7% malignant or suspected, were sent for surgery, malignancy was confirmed in 16/ 17 lesions. 14 (15.3%) were TPC and 2 lymphomas, the main subtypes were classic papillary and NHL, respectively. Mode of ATA risk was intermediate. Multivariate analysis only TIRADS represented risk factor (OR 2.08) Conclusions: The frequency of TC in our population was 15.3%, which reflects a higher prevalence of malignancy in thyroid nodules in patients with chronic thyroiditis, in accordance with what has been reported in other series. Presentation: 6/3/2024

A heterogeneous ultrasound open scanner for the real-time implementation of computationally demanding imaging methods.

Ultrasound open scanners have recently boosted the development and validation of novel imaging techniques. They are usually split into hardware- or software-oriented systems, depending on whether they process the echo data using embedded FPGAs/DSPs or a GPU on a host PC. The goal of this work was to realize a high-performance heterogeneous open scanner capable of leveraging the strengths of both hardware and software-oriented systems. The elaboration power of the 256-channel ultrasound advanced open platform (ULA-OP 256) was further enhanced by embedding a compact co-processing GPU system-on-module (SoM). By carefully avoiding latencies and overheads through low-level optimization work, an efficient PCIe communication interface was established between the GPU and the processing devices onboard the ULA-OP 256. As a proof of concept of the enhanced system, the high frame rate color flow mapping technique was implemented on the GPU SoM and tested. Compared to a previous DSP-based implementation, higher real-time frame rates were achieved together with unprecedented flexibility in setting crucial parameters such as the ensemble length (EL). For example, by setting EL=64 and a continuous-time high-pass filter, the flow was investigated with high temporal and spatial resolution in the femoral vein bifurcation (frame rate = 1.1 kHz) and carotid artery bulb (4.3 kHz), highlighting the flow disturbances due to valve aperture and secondary velocity components, respectively. The results of this work promote the development of other computational-expensive processing algorithms in real-time and may inspire the next generation of ultrasound high-performance heterogeneous scanners.

Evaluation of early and systematic ultrasound examination to determine postoperative dehiscence after small intestinal surgery (114 cases in dogs and cats).

To evaluate the feasibility and reliability of early ultrasound diagnosis for postsurgical bowel dehiscence and find the most reliable ultrasound criteria for dehiscence identification. Additionally, to determine the impact of early ultrasound detection of leakage in terms of survival and duration of hospitalization. Finally, to assess the need for systematized screening or checkup of the population at risk of dehiscence only. 31 cats and 83 dogs. A retrospective, records-based study was performed on 83 dogs and 31 cats (114 total) undergoing small intestinal surgery. Epidemiologic data, clinical signs, surgical procedures, pre- and postoperative ultrasound findings at 48 to 96 hours, hospitalization duration, complications, and general outcomes were recorded. Univariate and multivariate analyses were used to identify ultrasound findings associated with dehiscence. Dehiscence was suspected by ultrasound for 0 of 31 cats and 7 of 83 dogs (2 of 49 for enterotomy and 5 of 34 for enterectomy). Every suspected dehiscence was confirmed during revision surgery except one enterectomy revision, which was declined by the owner. Neither this case nor those without ultrasound evidence of dehiscence developed clinical signs of intestinal leakage. Direct visibility of wall discontinuity, presence of gas bubbles, and liquid in vicinity of the intestinal surgical site were statistically associated with early dehiscence. Survival rate after the second surgery was 83%. Median hospitalization time after the second surgery for dehiscence was 2 days (minimum, 2 days; maximum, 4 days). Postoperative ultrasound examination between 48 and 96 hours after intestinal surgery allows early and sensitive detection of intestinal dehiscence. Survival rate after revision surgery was significantly higher than that associated with septic peritonitis.

Establishment of seven lung ultrasound phenotypes: a retrospective observational study of an LUS registry

BackgroundLung phenotypes have been extensively utilized to assess lung injury and guide precise treatment. However, current phenotypic evaluation methods rely on CT scans and other techniques. Although lung ultrasound (LUS) is widely employed in critically ill patients, there is a lack of comprehensive and systematic identification of LUS phenotypes based on clinical data and assessment of their clinical value.MethodsOur study was based on a retrospective database. A total of 821 patients were included from September 2019 to October 2020. 1902 LUS examinations were performed in this period. Using a dataset of 55 LUS examinations focused on lung injuries, a group of experts developed an algorithm for classifying LUS phenotypes based on clinical practice, expert experience, and lecture review. This algorithm underwent validation and refinement with an additional 140 LUS images, leading to five iterative revisions and the generation of 1902 distinct LUS phenotypes. Subsequently, a validated machine learning algorithm was applied to these phenotypes. To assess the algorithm’s effectiveness, experts manually verified 30% of the phenotypes, confirming its efficacy. Using K-means cluster analysis and expert image selection from the 1902 LUS examinations, we established seven distinct LUS phenotypes. To further explore the diagnostic value of these phenotypes for clinical diagnosis, we investigated their auxiliary diagnostic capabilities.ResultsA total of 1902 LUS phenotypes were tested by randomly selecting 30% to verify the phenotypic accuracy. With the 1902 LUS phenotypes, seven lung ultrasound phenotypes were established through statistical K-means cluster analysis and expert screening. The acute respiratory distress syndrome (ARDS) exhibited gravity-dependent phenotypes, while the cardiogenic pulmonary edema exhibited nongravity phenotypes. The baseline characteristics of the 821 patients included age (66.14 ± 11.76), sex (560/321), heart rate (96.99 ± 23.75), mean arterial pressure (86.5 ± 13.57), Acute Physiology and Chronic Health Evaluation II (APACHE II)score (20.49 ± 8.60), and duration of ICU stay (24.50 ± 26.22); among the 821 patients, 78.8% were cured. In severe pneumonia patients, the gravity-dependent phenotype accounted for 42% of the cases, whereas the nongravity-dependent phenotype constituted 58%. These findings highlight the value of applying different LUS phenotypes in various diagnoses.ConclusionsSeven sets of LUS phenotypes were established through machine learning analysis of retrospective data; these phenotypes could represent the typical characteristics of patients with different types of critical illness.

Lung ultrasound in PEEP optimization for ARDS: a randomized controlled study

BackgroundPEEP optimization in acute respiratory distress syndrome (ARDS) is a controversial issue. Lung ultrasound (LUS) is a potential useful tool in PEEP optimization.AimThis study was intended to investigate the usefulness of LUS as a tool for PEEP optimization in ARDS patients.MethodsProspective randomized controlled trial conducted on ARDS patients that included 60 patients randomized in a 1:1 ratio to either PEEP/FiO2 table (group I) or lung ultrasound (group II).ResultsThe baseline findings showed more severe ARDS in group I patients with significantly lower P/F ratio (P = 0.008) and static compliance (P = 0.02). The use of LUS for PEEP optimization did not result in better improvement in P/F ratio (P = 0.4), PaCO2 (P = 0.2), or static compliance (P = 0.8). The use of LUS was associated with a favorable effect on hemodynamics with significantly less decrease in CO (P < 0.001), decreased TAPSE (P < 0.001), and less increase in right ventricular systolic pressure (P < 0.001). Despite that the inhospital mortality was significantly lower in group I, this result should be interpreted cautiously because the more severe the ARDS in group I.ConclusionOptimizing PEEP by lung ultrasound in mechanically ventilated ARDS patients might cause better outcomes in terms of oxygenation and hemodynamics indices despite the lack of effect on respiratory system mechanics. The use of LUS in PEEP optimization for ARDS patients needs to be more evaluated.