Excess Of Patients Research Articles

Access to primary care and mortality in excess for patients with cancer in France: Results from 21 French Cancer Registries.

The impact of geographical accessibility on cancer survival has been investigated in few studies, with most research focusing on access to reference care centers, using overall mortality and limited to specific cancer sites. This study aims to examine the association of access to primary care with mortality in excess of patients with the 10 most frequent cancers in France, while controlling for socioeconomic deprivation. This study included a total of 151,984 cases diagnosed with the 10 most common cancer sites in 21 French cancer registries between 2013 and 2015. Access to primary care was estimated using two indexes: the Accessibilité Potentielle Localisée index (access to general practitioners) and the Scale index (access to a range of primary care clinicians). Mortality in excess was modelized using an additive framework based on expected mortality based on lifetables and observed mortality. Patients living in areas with less access to primary care had a greater mortality in excess for some very common cancer sites like breast (women), lung (men), liver (men and women), and colorectal cancer (men), representing 46% of patients diagnosed in our sample. The maximum effect was found for breast cancer; the excess hazard ratio was estimated to be 1.69 (95% CI, 1.20-2.38) 1 year after diagnosis and 2.26 (95% CI, 1.07-4.80) 5 years after diagnosis. This study revealed that this differential access to primary care was associated with mortality in excess for patients with cancer and should become a priority for health policymakers to reduce these inequalities in health care accessibility.

Value of Surgical Cytoreduction in Patients with Small Intestinal Neuroendocrine Tumors Metastatic to the Liver and Peritoneum.

Cytoreductive hepatectomy can improve survival and symptoms of hormonal excess in patients with small intestinal neuroendocrine tumor (siNET) liver metastases, but whether to proceed when peritoneal metastases are encountered at the time of planned cytoreductive hepatectomy is controversial. This was a retrospective review of patients who underwent surgical management of metastatic siNETs at Mayo Clinic between 2000 and 2020. Patients who underwent cytoreductive operation for isolated liver metastases or both liver and peritoneal metastases were compared. Of 261 patients who underwent cytoreductive operation for siNETs, 211 had isolated liver metastases and 50 had liver and peritoneal metastases. Complete cytoreduction was achieved in 78% of patients with isolated liver metastases and 56% of those with liver and peritoneal metastases (p = 0.002). After complete cytoreduction, median overall survival (OS) was 11.5 years for isolated liver metastases and 11.2 years for liver and peritoneal metastases (p = 0.10), and relief of carcinoid syndrome was ≥ 97% in both groups. After incomplete cytoreduction with debulking of > 90% of hepatic disease and/or closing Lyon score of 1-2, median OS was 6.4 years for isolated liver metastases and 7.1years for liver and peritoneal metastases (p = 0.12). Patients with siNETs metastatic to both the liver and peritoneum have favorable outcomes after aggressive surgical cytoreduction, with the best outcomes observed after complete cytoreduction. Therefore, the presence of peritoneal metastases should not by itself preclude surgical cytoreduction in this population.

Assessing the Prognostic Significance of Lactate Levels and Arterial Base Excess in Patients After Pancreatic Surgery: A Retrospective Analysis

Assessing the Prognostic Significance of Lactate Levels and Arterial Base Excess in Patients After Pancreatic Surgery: A Retrospective Analysis

P719 Vitamin and micronutrient excess in patients with Crohn’s disease under oral ambulatory exclusive enteral nutrition

Abstract Background Exclusive enteral nutrition (EEN) is recommended for preoperative nutritional optimization (PNO) in adult Crohn's disease (CD) patients. However, during ambulatory oral EEN, a lack of routine monitoring for vitamins may occur, with a potential risk of hypervitaminosis-related toxicity, which remains unexplored. This study aims to assess the serum levels of vitamins and micronutrients in CD patients undergoing EEN and to examine its potential impact. Methods Complicated phenotype CD patients followed at a University Tertiary Hospital who were started on oral EEN June 2021 - June 2023 were prospectively included. EEN composition was determined and modified by an IBD nutritionist according to patients’ nutritional status and needs and laboratory values. Compliance was monitored daily, both for in- and outpatients. Patients’ weight and serum values (albumin, C-reactive protein [CRP], iron, folic acid, and vitamins B1, B6, B12, A, D, E and K) were monitored weekly. Results Nine patients (median age 29 years, 55.6% female) received a median of 24 (IQR 14.5-25.0) days of EEN, for PNO of symptomatic stricturing (7, 77.8%) or abdominal penetrating disease (2, 22.2%). All patients were discharged while on EEN, which was maintained until elective surgery (4, 44.4%) or the planned start of advanced medical therapy (5, 55.6%), with EEN successfully avoiding emergent surgeries. Patients were started on a combination of hypercaloric-hyperproteic and hypercaloric-normoproteic ready-to-drink concentrated polymeric formulas, providing 30 kcal/kg/d and 1.2-1.5g/kg/d of protein. EEN daily volume ranged from 1000 to 1400mL. Compliance was 100%, requiring flavour adjustments for tolerance. Table 1 illustrates changes over time in patients' weight and serum levels of interest. Resolution of anaemia and hypoalbuminemia was achieved, while weight was maintained . Hypervitaminosis cases were remarkably detected: 5 (55.6%) for vitamin B1, 4 (44.4%) for A, 2 (22.2%) for E, and 3 (33.3%) for K, with increasing trends over time. However, no symptoms related to hypervitaminosis were reported. Conclusion Our study on PNO EEN in CD uncovered a gap in routine monitoring for essential vitamins during EEN. While achieving significant clinical improvement, our findings revealed subtle and asymptomatic cases of hypervitaminosis in short-term EEN courses. These results underscore that vitamin monitoring is advisable during EEN, especially in prolonged EEN protocols due to possible hypervitaminosis-related toxicity.

FRI181 Increased LDL Particle And Apolipoprotein B Concentrations In Patients With Nonfunctioning And Cortisol Secreting Adrenal Adenomas

Abstract Disclosure: R. Sandooja: None. A. Kittithaworn: None. P. Dogra: None. D. Gruppen: None. E. Atkinson: None. S. Achenbach: None. K. Yu: None. M. Connelly: None. V. Simha: None. R.P. Dullaart: None. I. Bancos: None. INTRODUCTION: Based on the spectrum of cortisol excess, adrenal adenomas are classified as adenomas with Cushing syndrome (CS), adenomas with mild autonomous cortisol secretion (MACS), and non-functioning adenomas (NFA). Patients with adrenal adenomas demonstrate a high prevalence of cardiovascular morbidity and mortality proportional to the degree of hypercortisolism. Evidence on whether dyslipidemia is a contributing cardiovascular risk factor in patients with NFA and MACS is discrepant. We aimed to characterize (apo) lipoprotein abnormalities across the spectrum of cortisol excess in patients with adenomas as compared to referent subjects. METHODS: Study Design: Single center cross sectional study between 01/2015 - 05/2021.Patients: Adults with NFA, MACS, or CS were consecutively enrolled. MACS was diagnosed based on post-dexamethasone cortisol >1.8 mcg/dL. Referent subjects were recruited from local population of patients with available abdominal imaging and no adrenal disorders. All subjects provided fasting ethylenediaminetetraacetic acid (EDTA) venous samples. Measurements: Nuclear magnetic resonance (NMR) spectroscopy measurements included total cholesterol (TC), low-density lipoprotein (LDL) and LDL particle concentrations, high-density lipoprotein (HDL) subclasses, apolipoprotein B (apo B), triglycerides (TG) and TG-rich lipoprotein concentrations. RESULTS: Participants included 101 patients with CS (median age 44 years, IQR 31-58, 85% women), 158 patients with MACS (median age 62 years, IQR 51-70, 62% women), 166 patients with NFA (median age 60 years, IQR 53--66, 63% women) and 136 referent subjects (median age 68 years, IQR 57-77, 52% women). Patients had higher BMI (32 vs 27 kg/m2), higher prevalence of hypertension (72% vs 46%) and diabetes mellitus (27% vs 9%) as compared to reference subjects. Statin therapy was used in 32% of patients and referent subjects. After adjusting for age, sex, BMI, smoking, diabetes, hypertension, and statin therapy, as compared to referent subjects, we found inconsistent increase in TC, LDL cholesterol and TG across CS, MACS and NFA and no consistent differences in LDL size, HDL variables, TG and TG-rich lipoproteins. However, when compared to referent subjects, LDL particle concentrations- CS(OR 1.78, 95% CI 1.33-2.39), MACS (OR 1.31, 95% CI 1.03-1.67), and NFA (OR 1.43, 95% CI 1.12-1.82) and Apo B levels were higher in all patient categories: CS (OR 2.26, 95% CI 1.57-3.24), MACS (OR 1.36 95% CI 1.00-1.85 ), and NFA (OR 1.54 95% CI 1.13-2.09). These differences were particularly evident in patients not on statin therapy. CONCLUSIONS: We found that LDL particle and Apo B concentrations were elevated in all patient groups, including those with MACS and NFA. In comparison to conventional lipid measurements, LDL particle and Apo B may serve as a better biomarker of the future cardiovascular risk in patients with adrenal adenomas. Presentation: Friday, June 16, 2023

Utilizing dehydroepiandrosterone sulfate and its ratio for detecting mild autonomous cortisol excess in patients with adrenal incidentaloma.

Subclinical Cushing syndrome is a condition of mild autonomous cortisol excess (MACE) that lacks typical features of Cushing syndrome but is associated with many complications. It represents a common hormonal dysfunction among patients with adrenal incidentaloma (AI), defined as unexpected masses or lesions found in the adrenal glands during radiological examinations of the chest or abdomen unrelated to adrenal gland assessment. The study evaluated the accuracy of dehydroepiandrosterone sulfate (DHEA-S) and dehydroepiandrosterone sulfate ratio (calculated by dividing the DHEA-S value by the age and sex-adjusted normal range of DHEA-S) in detecting MACE in AI patients. A cross-sectional study was conducted from April 2021 to July 2022 at the Faiha Specialized Diabetes, Endocrine, and Metabolism Centre (FDEMC) in Basrah, southern Iraq, involving 38 AI patients. Comprehensive laboratory and radiological evaluations were performed, including tests for adrenocorticotropic hormone (ACTH), renin, aldosterone, aldosterone/renin ratio (ARR), metanephrine, normetanephrine, cortisol, DHEA-S, and the 1-mg overnight dexamethasone suppression test (1-mg ONDST). Among the AI patients, 14% had MACE. Both DHEA-S ≤75 µg/dL and a DHEA-S ratio ≤1.7 exhibited a sensitivity of 80% each, with specificities of 73.3% and 76.6%, respectively, in diagnosing MACE in individuals aged ≤65 years. The negative predictive values were 95.7% and 95.8%, respectively. Low DHEA-S and DHEA-S ratio had high sensitivity and specificity in predicting MACE among AI patients aged ≤65 years, with strong negative predictive value.

Impact of growth hormone on physical performance

Growth hormone (GH) is an anabolic hormone produced by the pituitary gland. The action of growth hormone is not only to promote growth in children, but it has a significant effect on metabolism and body composition also in adults. Growth hormone deficiency (GHD) leads to physical impairment (worsen muscle strength, aerobic and anaerobic capacity) and altered body composition - with increased fat and reduced lean body mass, particularly reduced skeletal muscle mass. On the other hand, GH excess in patients with acromegaly impairs physical function, especially aerobic capacity and muscle strength irrespective of GH-dependent muscle hypertrophy. There is unclear data about GH impact on physical performance among healthy populations. Some studies showed improvement in anaerobic capacity during recombinant human GH (rh-GH) administration, others showed no significant difference. Muscle strength did not improve after rh-GH administration among healthy adults. However, recombinant GH is abused by professional and recreational athletes to improve their physical performance.

Orexin-A/OX1R is involved in regulation of autophagy to promote cortisol secretion in adrenocortical cell

BackgroundHypercortisolism has emerged as a prominent clinical condition worldwide caused by biochemical cortisol excess in patients, and optimization treatment is needed urgently in the clinic. Previously, we observed that orexin-A/orexin type 1 receptor (OX1R) promoted cell proliferation, inhibited apoptosis, and increased cortisol release in adrenocortical cells. However, the functions of orexin-A/OX1R on autophagy and its molecular mechanism are not known. MethodsTransmission electron microscopy and confocal microscope were performed to detect autophagosomes. Western blot were performed to detect autophagy proteins. The cortisol concentration was assessed with an ELISA. FindingsOur data demonstrated that orexin-A/OX1R activated the mammalian target of rapamycin/p70 ribosomal protein S6 kinase-1 pathway, thereby inhibiting autophagy in H295R cells and Y-1 cells. Furthermore, the orexin-A/OX1R-mediated suppression of autophagy played a crucial role in cortisol secretion. Mechanistically, the expression of 3β-hydroxysteroid dehydrogenase/isomerase, the rate-limiting enzyme in cortisol synthesis, was increased with autophagy inhibition mediated by orexin-A/OX1R. InterpretationThis study provided the evidence that orexin-A/OX1R participated in modulating mTOR/p70S6K1/autophagy signaling pathway to promote cortisol secretion in adrenocortical cell. The findings suggest the mechanistic basis for disorders of cortisol secretion, providing the potential therapeutic targets for hypercortisolism treatment. FundThis work was supported by National Natural Science Foundation of China (32170603, 31871286), the Doctoral Start-up Foundation of Liaoning Province (20180540008, 2019-BS-298), the Natural Science Foundation of Liaoning Province (2019-ZD-0779), and Shenyang Science and Technology Plan Fund Projects (21-173-9-28).

Preoperative Base Excess as a Predictor of Perioperative Complications in Patients with Nonidiopathic Scoliosis who Have High Risk Associated with General Anesthesia.

Patients with nonidiopathic scoliosis often have a high risk associated with general anesthesia because of cardiac or pulmonary dysfunction secondary to underlying diseases. Base excess has been reported as a predictor in the management of trauma and cancer, although not yet in scoliosis. This study was performed to clarify the surgical outcomes and the association of perioperative complications with base excess in patients with nonidiopathic scoliosis who have a high risk associated with general anesthesia. Patients with nonidiopathic scoliosis who were referred to our institution from 2009 to 2020 because of their high risk associated with general anesthesia were retrospectively enrolled. High-risk factors for anesthesia were determined by a senior anesthesiologist and categorized into circulatory or pulmonary dysfunction. Perioperative complications were analyzed using the Clavien-Dindo classification; severe complications were defined as grade ≥III. We investigated high-risk factors for anesthesia, underlying diseases, preoperative and postoperative Cobb angle, surgery-related factors, base excess, and postoperative management. These variables were statistically compared between patients with and without complications. Thirty-six patients (mean age, 17.9 years old; range, 11-40 years old) were enrolled (two patients declined surgery). High-risk factors were circulatory dysfunction in 16 patients and pulmonary dysfunction in 20 patients. The mean Cobb angle improved from 85.1° (36°-128°) preoperatively to 43.6° (9°-83°) postoperatively. Three intraoperative complications and 23 postoperative complications occurred in 20 (55.6%) patients. Severe complications occurred in 10 (27.8%) patients. All patients underwent postoperative intensive care unit management after posterior all-screw construction. A large preoperative Cobb angle (p=0.021) and base excess outliers (>3 or <-3 mEq/L) (p=0.005) were significant risk factors for complications. Patients with nonidiopathic scoliosis who have a high risk associated with general anesthesia have a higher complication rate. Preoperative large deformity and base excess (>3 or <-3 mEq/L) could be predictors of complications.

Abstract #1408256: In Search of New Biomarkers of Thyroid Function: The Association Between Thyroid Dysfunction and 11-beta Hydroxysteroid Dehydrogenase 2 Activity

The high prevalence of persistent hypothyroid symptoms in patients with normal thyrotropin and free thyroxine levels calls for research to identify alternative biomarkers of thyroid function. Animal studies have shown thyroid hormones regulate the renal 11-beta hydroxysteroid dehydrogenase 2 (11βHSD2), a key enzyme in glucocorticoid metabolism. This study examines the impact of hypothyroidism (Overt and subclinical) and hyperthyroidism (overt and subclinical) on 11βHSD2 activity. In this single center prospective study conducted between July 2022-Dec 2022, 24-hour urine samples were collected from 6 patients with newly diagnosed hyperthyroidism, 6 with newly diagnosed hypothyroidism, and 33 age and sex matched healthy reference subjects. A quantitative analysis of 26 steroid metabolites was done in the hydrolyzed urine samples. Given that 11bHSD2 is responsible for the conversion of active cortisol to inactive cortisone, the cortisol to cortisone (F/E) ratio was used to evaluate the enzymatic activity. Differences in total glucocorticoid production and F/E ratios were analyzed based on Z-score deviations from the controls’ reference intervals. The mean participants’ age was 50 years, and 73.3% were female. In patients with hypothyroidism, the mean total glucocorticoid production was 12316.8 ng/mL which was similar to the reference subjects (Z-score -0.03, p = 0.9, CI 95%: -4691.4 to 4666.3), and the mean F/E ratio was 0.5 which was lower than the reference group (Z-score 2.6, p<0.01, CI 95%: 0.06-0.25). In patients with hyperthyroidism, the mean total glucocorticoid production was 16933.7 ng/mL, which was non-statistically higher than the reference subjects (Z-score 1.2, p = 0.1, CI 95%: -794 to 10269), and the mean F/E ratio was 0.4 which was non-statistically higher than the reference group (Z-score 1.6, p = 0.09, CI 95%: 0.01-0.25). After adjustment analysis for total glucocorticoid production, only the differences in the F/E ratio of the hypothyroid patients remained statistically significant (p<0.01). In this proof of principle study, patients with hypothyroidism appeared to have normal total glucocorticoid production but impaired 11βHSD2 activity. Further studies are needed to confirm these findings, determine any clinical implications from cortisol excess in patients with thyroid dysfunction, and evaluate the utility of glucocorticoid metabolomics as a biomarker of peripheral thyroid function action.

Assessment of Volume Status in Chronic Hemodialysis: Comparison of Lung Ultrasound to Clinical Practice and Bioimpedance

Objective: To compare LUS with other volume assessment methods, and to verify the prognostic value of LUS in Thai chronic HD patients.&#x0D; Materials and Methods: We conducted a prospective cohort study in 36 chronic HD patients. Volume status before the HD session was evaluated by physical examinations, bioimpedance analysis (BIA), and ultrasound lung comets (ULCs). Mortality and morbidities were recorded during a 1-year follow-up period.&#x0D; Results: The degree of lung fluid accumulation was assessed by summation of the number of ULCs, and was classified into 3 groups: mild-to-moderate (ULC&lt;15–29), severe (ULC=30–59), and very severe (ULC&gt;60) in 11.1%, 77.8%, and 11.1% of the patients, respectively. Either clinical edema or lung crackle had low sensitivity (20-32%) to detect extravascular lung water excess in patient with mild-to-moderate ULC and severe ULC. Overhydration assessed by BIA was found in 75% and 64.3% of patients with mild-to-moderate and severe ULC, respecively. In patients with very severe ULC, the admission rate due to volume overload was significantly higher, there was also a trend of increased mortality, as well as intradialytic complications.&#x0D; Conclusion: Clinical assessment and BIA have limited value in determining extravascular fluid excess in the lung. Lung ultrasound is a useful tool to detect subclinical pulmonary congestion. The long-term outcome by using LUS-guided fluid management needs larger population studies.

The use of platelet-rich plasma, hyaluronic acid, and botulinum toxin for the treatment of TMJ disorders

The temporomandibular joint (TMJ) is a synovial joint that connects the mandibular to the skull. Its main function is to facilitate the movement of the jaw and when it suffers any type of damage or injury, it leads to a decrease in mobility and pain in the area. This localized pain is called temporomandibular joint disorders (TMJD), and it can be caused by intraarticular or extraarticular disorders. The most common symptoms include acute pain, decreased mouth opening, tightening of the muscle, headache, and loss of joint function. Nowadays, there are treatments for temporomandibular joint dysfunction from surgical procedures up to less invasive methods, such as the use of splints. Platelet rich plasma (PRP), hyaluronic acid (HA) and botulinum toxin (BTX) injections have been categorized as a complement of primary treatment in TMJD, as well as decrease drug excess in patients. Due to their natural origin, PRP and HA can regenerate tissue in cases of cartilage degeneration, inhibit inflammation, slow down the progression of osteoarthritis and increase the production of natural lubricating fluid in the joint. Its intra-articular application reduces pain due to lubrication and nutrition to the avascular areas of the disc and condylar cartilage. Botulinum toxin (BTX) has been used for years in the medical and cosmetic field, but its use in TMJD refers to injections specifically within masseter muscle, with the objective to reduce the muscular tension TMJ overload, therefore, pain decreases, and movement increases. Over the years these less invasive methods have been increasing in the medical area due to the great pain management in the neuro-muscular and articular complex.

Hepatic and cardiac iron overload quantified by magnetic resonance imaging in patients on hemodialysis: A systematic review and meta-analysis.

Few studies have reported hepatic and cardiac iron overload in patients with end-stage renal disease (ESRD), and the current evidence regarding the prevalence is still scarce. This review aims to estimate the prevalence of hepatic and/or cardiac iron overload quantified by magnetic resonance imaging (MRI) in patients with ESRD who receive hemodialysis (HD), peritoneal dialysis (PD), or have undergone a kidney transplant. A systematic review with meta-analysis was conducted and reported in line with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. MEDLINE and Embase bibliographic databases were searched using a comprehensive list of controlled vocabulary and keywords to identify relevant studies. All studies reporting the prevalence of hepatic and/or cardiac iron overload quantified by MRI in ESRD patients were considered. The Newcastle-Ottawa scale was used to assess the methodological quality of included studies. To investigate the heterogeneity between studies, random-effect meta-analyses for proportions were used. The review comprised seven studies that included 339 patients. Using meta-analysis, the pooled prevalence of severe and mild to moderate hepatic iron overload quantified by MRI was 0.23 [95% CI: 0.08-0.43] and 0.52 [95% CI: 0.47-0.57], respectively. Only three studies included cardiac iron quantification, and none reported iron overload. This review has revealed a high prevalence of severe hepatic iron overload in patients with ESRD treated by HD. Further studies with a larger sample size are needed to determine the impact of iron overload on vital organs in patients with ESRD and guide future research in this understudied field. Proper use of iron chelation and continuous monitoring will help in the early detection of unsolicited complications; however, the low renal clearance of most iron chelators limits the options for treating iron excess in patients with ESRD.

OR12-1 Activity of Abiraterone Acetate in the management of Cushing syndrome associated to advanced adrenocortical carcinoma: results of the ABACUS trial.

Abstract Background More than 50% of adrenocortical carcinomas (ACC) in adults are associated with cortisol excess that makes tumor management challenging and has a negative impact on patient outcome. Abiraterone acetate (AA) is an irreversible inhibitor of the 17α-hydroxylase/C17, 20-lyase (CYP17 enzyme) that is used in patients with prostate cancer, in whom it leads to suppression of cortisol and androgens. Thus, the drug is potentially useful in the medical treatment of steroid-secreting tumors. The aim of this study was to assess the activity of AA to control cortisol excess in patients with advanced ACC and overt Cushing syndrome. Methods We designed the phase II trial ABACUS (NCT 03145285) whose primary endpoint was normalization of 24-h urinary free cortisol (UFC) excretion within 1 month from treatment start. Inclusion criteria were histologically proven ACC, locally advanced or metastatic disease, and Cushing syndrome confirmed by two 24-h UFC &amp;gt;1.5 times the upper normal limit with suppressed ACTH. No concomitant treatment with mitotane or chemotherapy was allowed for the first 4 weeks of the study. AA was given orally at the daily dose of 1000 mg. Results From 2017 to 2019, we included 17 patients with ACC (2 stage III, 15 stage IV), 13 women (76%), median age 51 years (18-76), of whom 8 have been heavily pretreated and 9 were treatment naïve. In 8 patients, multiple steroid secretion was found. Patients were treated with AA for a median of 17 days (7-163). Median 24-h UFC (measured by gas-mass spectrometry) was 368 μg/24h (121-7422) at baseline and 94 μg/24h (20-1793) at end of treatment (p=0.01). Normalization of 24-h UFC was attained in 8 patients (53%) and a &amp;gt;50% decrement in 11 patients (73%). The median time to effect was 21 days and median 24-h UFC reduction 81.8% (-97.7 - +25.9). Androgen and precursor steroids were also significantly reduced by AA treatment. The median Cushing Syndrome Score was 5.0 (2 - 8) at baseline and 3.5 (1 - 6) at the end of treatment, thus confirming clinical improvement. Blood pressure was significantly reduced and hypokalemia was not observed. In 2 patients, treatment was discontinued for toxicity. Seven patients died of ACC progression during follow-up with an overall survival of 5.4 months (0.5-39.3). Conclusions AA was able to control rapidly cortisol excess in most patients with a good safety profile. The results of this proof-of-concept study show that AA looks promising and may be viewed as an additional weapon to manage Cushing syndrome in patients with ACC. These findings pose the basis for power calculation and implementation of a prospective long-term study to establish AA efficacy in patients with a steroid-secreting ACC. Presentation: Sunday, June 12, 2022 11:00 a.m. - 11:15 a.m.

LBODP024 Successful Adrenal Vein Sampling Using Dexamethasone Premedication In Patients With Iodine Contrast Media Allergy

Abstract Background Preparation of patients with iodine contrast media (ICM) allergy who require adrenal vein sampling (AVS) to establish source of aldosterone excess in confirmed primary aldosteronism (PA) is controversial. Usual premedication with high dose prednisone can interfere with cortisol determinations, possibly altering the aldosterone-to-cortisol ratios for the identification of lateralized aldosterone excess. Objective Evaluate the efficacy and safety of premedication with high dose dexamethasone to perform AVS in patients with ICM. Methods 177 consecutive patients with confirmed PA who underwent bilateral simultaneous basal and post ACTH bolus AVS at our center between January 2010 and December 2020 were retrospectively analyzed for reported ICM allergy. A total of 7 patients (4%) with history of allergic reactions to ICM were premedicated with three doses of 7.5 mg dexamethasone rather than the usual 50 mg of prednisone. Results No breakthrough allergic reactions were reported in the 7 patients. The mean age at the time of AVS procedure was 55.1 ± 16.8 years. Patients had been hypertensive for a mean of 6.7 ± 5.9 years. The mean systolic blood pressure on the day of the procedure was 137.4 ± 4.2 mmHg and the mean diastolic blood pressure 77.1 ± 12.9 mmHg. Most patients had at least 2 anti-hypertensive medications in their drug regimen prior to AVS procedure, none being mineralocorticoid receptor antagonists. Dexamethasone suppression effect on AVS: All basal peripheral cortisol levels were suppressed, &amp;lt; 50 nmol/L, confirming lack of meaningful cortisol co-secretion. The basal and post-ACTH selectivity index were respectively &amp;gt;2 and &amp;gt; 5 bilaterally in all patients, confirming adequate cannulation of both adrenal veins. Basal peripheral plasma aldosterone concentration (PAC) was also reduced by dexamethasone administration by an average of 66 ± 30% in comparison with PAC measured before AVS. Despite basal suppression, PAC increased following ACTH bolus injection with an average rise of 698.8 ± 644.5% from baseline. AVS results: Four patients had lateralized (A/C ratio &amp;gt; 2 basally and &amp;gt;4 post ACTH), while three had bilateral source according to AVS results. Follow up data for a mean of 58 ± 41.4 months was available for 6 patients. In the three patients who underwent unilateraladrenalectomy for lateralized source, basal and post-ACTH lateralization ratios were concordant. All 3 patients had contralateral suppression, confirmed adrenocortical adenoma at histopathology and clinical (n=3) (normal blood pressure without medication) and/or biochemical cure (n=2) (direct renin concentration &amp;gt; 10 ng/dL) at follow up. Conclusion AVS using dexamethasone premedication is safe and accurate for diagnosing source of aldosterone excess in patients with PA and ICM allergy. Presentation: No date and time listed

Biomarkers of Allostatic Load in Patients with Diabetic Retinopathy

Diabetic retinopathy occupies a special place among the causes of the progression of decrease and loss of visual acuity, significantly impairing the quality of life and age-related viability, an integral indicator that is considered allostatic load. However, the allostatic load in patients suffering from diabetic retinopathy, as well as in other ophthalmological diseases, has not been practically studied and biomarkers characterizing the allostatic load of patients with diabetic retinopathy remain unknown.Purpose. To study of allostatic load in patients with diabetic retinopathy and the identification of biomarkers that most determine it.Patients and methods. Allostatic load was studied in 78 elderly patients with diabetic retinopathy and in 62 patients with type 2 diabetes mellitus without diabetic retinopathy. Allostatic load was analyzed according to systolic and diastolic blood pressure, body mass index, glycated hemoglobin, total cholesterol, triglycerides, albumins, C-reactive protein, homocysteine in the blood and glomerular filtration rate.Results. The most pronounced and statistically significant excess in patients with diabetic retinopathy compared with patients with diabetes mellitus without diabetic retinopathy was found to be the content of glycated hemoglobin in the blood up to 10.2 % versus 7.4 % and homocysteine up to 15.5 mmol/l versus 7.9 mmol/l, respectively. The value of the allostatic index was significantly higher in patients with diabetic retinopathy, amounting to 4.6 ± 0.4 points, versus 2.9 ± 0.3 points in patients with diabetes mellitus without ophthalmopathology under consideration (p &lt; 0.001). Factor analysis made it possible to identify biomarkers of allostatic load in patients with diabetic retinopathy — glycated hemoglobin, homocysteine, triglycerides and albumins.Conclusion. These biomarkers are proposed to be used in assessing the age-related viability and effectiveness of rehabilitation measures carried out among patients with diabetic retinopathy.

A Quality Improvement Effort to Reduce Inpatient Opioid Consumption following Cesarean Delivery.

The amount of opioid prescribed following cesarean delivery (CD) is commonly in excess of patients' needs. An additional concern in a breastfeeding mother is neonatal opioid exposure. A maximum daily dose of 30 mg of oxycodone is recommended in breastfeeding women. Inadequate pain control can inhibit breastfeeding, as well as other negative consequences. We aimed to evaluate the effect of reducing the as-needed opioid ordered following CD on inpatient opioid consumption and analgesia. At our tertiary-care institution, our standard as-needed opioid order was reduced from oxycodone 5 to 10 mg every 4 hours to oxycodone 5 mg every 6 hours, in May 2019. Orders for scheduled acetaminophen and nonsteroidal anti-inflammatory drugs were unchanged. We compared opioid use and pain scores before (February 2019-April 2019) and after (May 2019-July 2019) the order modification. Our primary outcome was the proportion of patients using >30 mg of oxycodone in the 24 hours prior to hospital discharge. We further assessed 48-hour opioid consumption and patient-reported verbal pain scores. There were 559 patients who met inclusion criteria; 241 preintervention patients and 318 postintervention patients. In the preintervention group, 14.5% (35/241) used >30-mg oxycodone in the 24 hours before discharge, compared with 5.0% (16/318) after the order set change (relative risk [RR] = 0.34, 95% confidence interval [CI]: 0.19, 0.61; number needed to treat [NNT] = 10.5). There was no change in the proportion of women with one or more pain score >7 (preintervention: 44.4% [107/241], postintervention: 43.1% [137/318], p = 0.756) or >4 and ≤7 (preintervention: 36.9% [89/241], postintervention: 36.9% [125/318], p = 0.567), nor was there a change in mean pain score (mean ± standard deviation [SD]: preintervention = 2.8 ± 1.6 and postintervention = 2.7 ± 1.4, p = 0.464). Reducing the amount of opioid ordered after CD reduced the proportion of post-CD patients exceeding the maximum recommended daily oxycodone dose for breastfeeding women. · Inpatient opioid prescribing influences usage.. · Opioid orders influence consumption.. · Reducing opioids may not increase pain..

Successful Adrenal Vein Sampling Using Dexamethasone Premedication in Patients With Iodine Contrast Media Allergy.

ContextPreparation of patients with iodine contrast media (ICM) allergy who require adrenal vein sampling (AVS) to establish source of aldosterone excess of their confirmed primary aldosteronism (PA) is controversial. Usual premedication with high-dose prednisone can interfere with cortisol determinations, possibly altering the aldosterone to cortisol ratios for the identification of lateralized aldosterone excess.ObjectiveWe aimed to evaluate the efficacy and safety of premedication with high-dose dexamethasone to perform AVS in patients with ICM.MethodsOne hundred and seventy-seven consecutive patients with confirmed PA who underwent bilateral simultaneous basal and post-ACTH bolus AVS at our center between January 2010 and December 2020 were retrospectively analyzed for history of ICM allergy. A total of 7 patients (4%) with previous allergic reactions to ICM were prepared with 3 doses of 7.5 mg dexamethasone premedication rather than the usual 50 mg of prednisone.ResultsNo breakthrough allergic reactions were reported in the 7 patients. Despite adequate serum cortisol suppression following dexamethasone, the basal and post-ACTH selectivity index were respectively > 2 and > 5 bilaterally in all patients, confirming adequate cannulation of both adrenal veins. Four patients had lateralized ratios (A/C ratio > 2 basally and > 4 post-ACTH), while 3 had bilateral source during AVS study. In the 3 patients undergoing unilateral adrenalectomy for lateralized source and contralateral suppression and adequate follow-up data, cure of PA was achieved at mean 58 months postoperatively.ConclusionAVS using dexamethasone premedication is safe and accurate for diagnosing the source of aldosterone excess in patients with PA and ICM allergy.

Sources of excess steroid prescriptions and clinical adverse outcomes associated with steroid excess in patients with inflammatory bowel disease: The Leeds IBD Steroids study.

Corticosteroids remain important for managing inflammatory bowel disease (IBD) flares. Steroid excess, however, may be a marker of poor care. Patients access steroid prescriptions from primary (General Practitioners [GP]) or secondary care (hospital-based). Sources of prescriptions and associated outcomes are not well described. Patients attending IBD clinics with linked primary care information were included. We examined appropriateness and timeliness of treatment escalation and avoidability of steroid excess in relation to prescription sources. Of 2246 patients, 33% were exposed to steroids over 2 years. Primary care issued 28% of prescriptions. Secondary care prescriptions were more often of appropriate dose and duration (85% vs 41%, p< 0.001). Further flares occurred in 50% of patients prescribed steroids from primary care (vs 39%; p= 0.003). Steroid excess was observed in 15%. Patients with steroid excess who received prescriptions from primary care that were not communicated to secondary care less often received timely treatment escalation (49% vs 66%, p= 0.042) and steroid excess was more often avoidable (73% vs 56%, p= 0.022). Patients with steroid excess had higher risks of hospitalisation for IBD (OR=12.33, 95% CI [8.89-17.11]), hospitalisation for infections (OR=2.89, 95% CI [1.82-4.61]) and GP prescribed antibiotics (OR=1.41, 95% CI [1.07-1.86]). Patients commonly access steroids through primary care, but doses and durations are frequently inappropriate with patients more likely to flare. Steroid excess was associated with IBD admissions, admissions for infections and antibiotic prescriptions. Improved liaison between primary and secondary care is required to reduce steroid excess.

Visceral Adiposity Index Is Associated with the Increased Syntax Score in Patients with Type 2 Diabetes Mellitus.

Background: The visceral adipose tissue excess in patients with diabetes mellitus (DM) is one of the mechanisms that plays role in the development of coronary atherosclerosis. Our study aimed to investigate the relationship between visceral adiposity index (VAI), an indicator of visceral adiposity, and Syntax score (SxS), a predictor of the severity of coronary artery disease (CAD), in patients with stable angina pectoris (SAP) and type 2 DM. Methods: A total of 253 patients with SAP and type 2 DM were included in this cross-sectional study. The patients were divided into three risk groups (low risk <22, 32 ≥ intermediate risk ≥22, high risk ≥33) according to the SxS based on invasive coronary angiography. Several adiposity indexes such as body mass index, waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), body adiposity index (BAI), and lipid accumulation product index (LAPI) were calculated using relevant formulas. In addition, VAI scores for each patient were calculated. Results: There were no statistically significant differences between the low-, intermediate-, and high-risk groups for WHtR, BAI, and LAPI. WHR was found significantly lower in the low SxS group (P = 0.0038), and VAI was found significantly higher (P = 0.021) in the high SxS group. Besides, in multivariate logistic regression analysis, the VAI (odds ratio: 2.455; 95% confidence interval: 1.244-4.845; P = 0.010) was an independent predictor of high SxS. In the receiver operating characteristic curve analysis, VAI with an optimal cutoff value of 2.048 predicted the severe coronary lesion with a sensitivity of 60.8% and a specificity of 61.5%. Conclusion: This study showed that VAI was an independent predictor in estimating CAD severity in patients with SAP and type 2 DM.