Left Side Research Articles

The association between pan-immune-inflammation value and chronic obstructive pulmonary disease: data from NHANES 1999-2018.

The pan-immune-inflammation value (PIV) is an emerging biomarker quantitatively reflecting the systemic immune-inflammatory status. The predictive value of PIV has been well-established across various clinical settings. However, its role in chronic obstructive pulmonary disease (COPD) remains unclear and necessitates further investigation. Data from NHANES 1999-2018 were filtered. Logistic regression analyses were used to assess the correlation between COPD prevalence and PIV in all participants. COX regression analyses and Kaplan-Meier survival curves were used to investigate the relationship between COPD all-cause mortality and PIV in COPD patients. Restricted cubic spline (RCS) analyses and piecewise linear regression analyses were additionally employed to explore the correlation between PIV and COPD. Subgroup analyses were performed to further clarify the effects of other covariates on the associations. Sensitivity analyses were employed to assess the robustness of the results. A total of 28,485 participants aged 40years and older were recruited for this study. After fully adjusting for covariates, higher PIV levels were independently associated with increased COPD prevalence (OR = 1.67; 95% CI: 1.39-2.01) and all-cause mortality (HR = 2.04; 95% CI: 1.41-2.95). The COPD prevalence curve exhibited an inflection point at Log10-PIV of 2.24, showing no significant correlation on the left side (OR = 0.86; 95% CI: 0.45-1.64) but a positive correlation on the right side (OR = 2.00; 95% CI: 1.57-2.55). The COPD all-cause mortality curve displayed an inflection point at Log10-PIV of 2.38, indicating a negative correlation on the left side (HR = 0.23; 95% CI: 0.12-0.44) and a positive correlation on the right side (HR = 4.12; 95% CI: 2.62-6.48). Subgroup analyses with interaction tests showed that the strength of the correlation between PIV and COPD prevalence was influenced by race, smoking status, and BMI (all p for interaction <0.05). The relationship between PIV and COPD all-cause mortality was unaffected by any covariates (all p for interaction >0.05). Elevated PIV levels are associated with increased COPD prevalence. COPD patients with either elevated or reduced PIV levels experience higher all-cause mortality. Further large-scale, longitudinal studies are required to corroborate these findings.

ANALYZING THE RELATIONSHIP AMONG CLINICAL SYMPTOMS, X-RAY RESULTS, AND CARTILAGE WEAR PATTERNS IN KNEE OSTEOARTHRITIS USING T2 MAPPING MRI

Objectives: Osteoarthritis (OA) is a condition that causes joint pain, varying degrees of functional limitations, and a decrease in overall quality of life. The purpose of this study was to examine the progression of cartilage degeneration in knees affected by symptomatic OA and determine its relationship with X-ray and T2 map MRI findings. Methods: This study was conducted at a Tertiary Care Teaching Institute in India and involved 40 patients. It was an observational type of study. For our assessment, we utilized the Western Ontario and McMaster University (WOMAC) osteoarthrosis index to evaluate function, quality of life, and joint pain. Medical imaging technique A standing AP view of the affected knee joint was taken using plain radiographs. Once the X-rays were obtained, they were graded using the Kellgren–Lawrence Classification, which ranges from 0 to 4 grades. Results: Out of the total patients, 6.0% were &lt;40 years old, 21.2% were between 41 and 50 years old, 27.2% were between 51 and 60 years old, 39.3% were between 61 and 70 years old, and 6.0% were above 70 years old. In this study, there were 21 females (63.6%) and 12 males (36.4%). In this study, the researchers found that there was no distinction between the sides of the limb affected. Both the left and right sides were involved in 13 cases each, accounting for 39.39% of the total cases. In addition, 7 cases, or 21.21%, reported experiencing bilateral knee pain. Merchant grade reported that out of the knees examined, 17.5% had Grade 0, 45% had Grade 1, 27.5% had Grade 2, 10% had Grade 3, and none had Grade 4. Conclusion: The findings of this study suggest that T2 map MRI has the ability to accurately measure abnormal cartilage changes in conditions that affect the mechanical properties of the knee joint. It is crucial to have non-invasive methods that can assess early cartilage matrix changes. These methods are important for initiating early treatment, monitoring disease progression, planning operative procedures, and following up on operative cartilage repair.

Severe hydronephrosis complicated with primary aldosteronism: a case report and review of the literature

BackgroundPrimary aldosteronism is characterized by high plasma aldosterone and low renin. The plasma aldosterone-to-renin ratio is recommended for screening. Severe hydronephrosis leads to renal parenchymal ischemia, resulting in increased renin secretion. Since nonsuppression of renin may cause a negative result in the aldosterone-to-renin ratio test, severe hydronephrosis and primary aldosteronism occurring simultaneously in a patient are challenging to diagnose.Case presentationA 54-year-old Chinese man of Han ethnicity was diagnosed with hypertension and severe hypokalemia (minimum 1.57 mmol/L) 13 years prior, and was also diagnosed with severe hydronephrosis due to congenital ureteral stenosis on the left side. His clinical features suggested primary aldosteronism, but the aldosterone-to-renin ratio result of the patient was negative every time he underwent the primary aldosteronism screening test. No further treatment for primary aldosteronism was performed, which led the patient to suffer from severe hypokalemia, such that he was taking 12–15 g/day potassium chloride orally to keep his blood potassium between 3.0 and 3.5 mmol/L (reference value, 3.5–5.5 mmol/L) for 13 years, and the patient needed to be hospitalized in the intensive care unit for rescue several times. At admission, although the aldosterone-to-renin ratio result of the patient was negative, we still did the saline stress test and captopril inhibition test, and the results showed that the plasma aldosterone level was not lower after the test than before the test. Adrenal enhanced computed tomography suggested an adenoma in the left adrenal gland, and the results of adrenal vein sampling suggested that the left side was the dominant side. Therefore, laparoscopic total resection of the left adrenal gland was performed, and 2 weeks later, the patient developed short-term renal function impairment and hyperkalemia, but his renal function and blood potassium returned to normal after treatment that included fluid rehydration. The patient’s biochemical test results and clinical symptoms were completely normal after 1 year.ConclusionWe suggest that for patients with a high suspicion of primary aldosteronism in the clinic, comprehensive analysis must be performed in combination with clinical characteristic assessments, such as severe hydronephrosis, if renin is within the normal range or if the aldosterone-to-renin ratio result is negative at screening and diagnostic tests, and adrenal vein sampling should be performed if necessary. It can help avoid misdiagnoses and contribute to the treatment of patients with severe hydronephrosis and primary aldosteronism.

7824 Orbital Lymphoma masquerading as Thyroid Eye Disease

Abstract Disclosure: S. Ganawa: None. S. Joseph: None. C. Anshuman: None. D. Luciane L: None. A. Sajid: None. C. Anne: None. S. Dhage: None. Thyroid eye disease (TED) is the most common extrathyroidal manifestation in Graves’ disease (GD). In this case report, we present a case of a 64 years old lady, who was initially diagnosed with thyroid eye disease about 9 years ago. However, she was clinically and biochemically euthyroid. She was offered an orbital decompression surgery by local ophthalmology team. Patient wasn’t keen on the surgery at this stage.Recently she experienced increased swelling of her eyes, with conjunctival redness, oedema, and diplopia bilaterally, more evident on the left side. She was initiated on intravenous methylprednisolone (IVMP) weekly, by local ophthalmology team and was referred to our specialist thyroid eye clinic for further management.On presentation to us, her clinical activity score (CAS) was 5/7, but she was euthyroid clinically and biochemically. She was continued on weekly IVMP and oral mycophenolate mofetil (MMF) was added on as per the latest EUGOGO guidelines published in 2021. Her treatment was reviewed after the anti thyroperoxidase (TPO) and anti-Thyroid Stimulating Hormone receptor (TSH) antibodies were reported as negative and her eyes worsened despite the treatment with IVMP and MMF.Her repeat MR orbit at this stage showed possible orbital lymphoma. Her immunosuppressive medications were discontinued at this stage. After further discussions at regional thyroid eye MDT and radiology MDT, an orbital biopsy was arranged for, which confirmed Extra nodal Marginal Zone lymphoma, with no high-grade component. She has been referred to the oncology unit for further assessment and management.This case highlights the importance of considering alternative differential diagnosis in certain patients with atypical features or those who are non-responders to the first line immunosuppressive therapies for thyroid eye disease. Details of this case and relevant literature will be reviewed in this report. Presentation: 6/3/2024

7428 Clinical and Radiological Characterization and Outcomes of Lipid-Poor Adrenal Masses- A Multi-Center Retrospective Study

Abstract Disclosure: V. Balderrama-Brondani: None. R. Al-ward: None. K. Kiseljak-Vassiliades: None. L.M. Fishbein: None. D.A. Kirelik: None. O. Hamidi: None. R. Pishdad: None. H.K. Ghayee: None. M. Sukkari: None. S.S. Bedrose: None. A.H. Hamrahian: None. M.A. Habra: None. Background: Lipid-poor adrenal masses (LPAMs) with pre-contrast radiodensity &amp;gt;10 Hounsfield Units (HU) on computed tomography (CT) represent ∼25% of adrenal tumors. There is limited data about the natural history of LPAMs; therefore, we evaluated a large series of patients with LPAMs to describe the radiological and clinical features and outcomes of these cases. Methods: We conducted a multi-center retrospective cohort study of patients with LPAMs with a baseline diameter of 10-39 mm and derived from 6 institution members of the American-Australian-Asian Adrenal Alliance (A5). We excluded suspected or proven adrenal metastasis, pheochromocytoma, sarcoma, lymphoma, myelolipoma, infiltrative lesions, and adrenal hemorrhage, as well as patients with personal/familial history of genetic predisposition to adrenal neoplasms. The data is presented in percentage and median (range). Results: A total of 242 adrenal masses from 218 patients were evaluated, but only 225 (93%) masses met the inclusion criteria and were analyzed. The age was 58 (23-92), and 61% were women. LPAMs were incidentally discovered in 155 (71.1%) cases, 32 (14.7%) cases were diagnosed due to hormonal overproduction, and 17 (7.8%) due to pain/mass effect. Forty-six (21.1%) patients were on surveillance for a history of extra adrenal malignancy. Masses were unilateral in 89.9% (left side, 57.1%), with size 21 (10-38) mm, with a pre-contrast density of 24 (11-136) HU. Absolute washout was reported in 107 LPAMs and was &amp;gt;60% in 73 (68.2%) cases. The follow-up time was 44.4 (0.9-241) months. Hormonal overproduction developed during the follow-up in 23 (10.5%) cases as follows: cortisol in 15 (6.9%), aldosterone in 4 (1.8%), and sex hormones in 3 (1.4%) cases. LPAM growth rate was 0.03 (-2.18-11.59) cm/year. Seventy-one masses (31.5%) underwent diagnostic procedures (surgery/biopsy) with adrenocortical adenoma (n=37; 52.1%) and adrenocortical carcinoma (ACC) (n=25; 35.2%) being the two most common diagnoses. The tumor growth rate of pathologically confirmed adenomas was 0.03 (-0.30-10.50) cm/year, and of ACC was 1.31 (0.03-11.59) cm/year. A total of 154 (68.4%) LPAMs remained under surveillance at the end of the study, with a follow-up time of 51.8 (6-241) months and a tumor growth rate of 0.02 (-2.18-1.36) cm/year. Forty-five (20.6%) LPAMs decreased by 2 mm (1-13) during the study period. Cases that proved to be ACC had the most significant tumor growth rate over the study (p&amp;lt;0.001). The median time between the initial discovery of LPAM and the surgical resection of ACC cases was 34 (6-128) months. Conclusion: Our study showed that LPAMs carry significant malignant potential, and close long-term follow-up is warranted when surgical resection is not pursued. Prospective studies are critically needed to validate our findings and to establish high-risk molecular, imaging, and biochemical features associated with malignancy. Presentation: 6/2/2024

7648 Bilateral Adrenal Hemorrhage After Laminectomy: A Rare Complication

Abstract Disclosure: M. Rizk: None. S. Sharma: None. H. Qadeer: None. R. Paudel: None. C. Sherpa: None. Introduction: Bilateral Adrenal Hemorrhage (BAH) is an exceedingly uncommon complication of laminectomy, with few cases reported in the literature. In patients with history of any surgical procedure who present with unexplained symptoms of abdominal pain, back pain, hypotension, fever, confusion, or electrolyte abnormalities especially hyponatremia, acute adrenal insufficiency (AI) should be highly suspected. We herein describe a case of BAH following laminectomy. Clinical Case: 63-year-old male with past medical history of hypertriglyceridemia was admitted for post traumatic L1 burst fracture and was treated with T11-L3 fusion and T12-L3 laminectomy. The patient had normal bilateral adrenal glands after the fall on CT thoracic/lumbar spine imaging. The course was complicated by thrombocytopenia initially thought to be induced by therapeutic heparin since heparin antibody was positive. Serotonin-release assay returned negative weeks later ruling out heparin induced thrombocytopenia. Two weeks later, he developed unexplained tachycardia and CT angiogram was done which showed segmental pulmonary embolism and bilateral adrenal nodules measuring at least 3.9 cm on right side and 3.3 cm on left side. He was treated with Eliquis and was discharged home. Two weeks later, he was readmitted with weight loss of 30 lbs, weakness and altered mental status. His vital signs were significant for hypotension and tachycardia. Initial work up showed profound hyponatremia (sodium 121 mEq/L), hyperkalemia (potassium 6.1 mEq/L), hypoglycemia (Glucose 58 mg/dL), hypercalcemia (calcium 11.7 mg/dL) and acute kidney injury (creatinine 2.58 mg/dL). Repeat CT scan of chest/abdomen/pelvis without contrast showed bilateral hyperdense 4 cm adrenal mass/hematoma. Since initial CT of thorax/spine done after the fall showed normal adrenal glands, the new bilateral hyperdense adrenal masses noted post procedure is suggestive of adrenal hemorrhage/hematoma. Undetectable cortisol and high ACTH confirmed AI. Patient was treated with stress dose hydrocortisone followed by slow taper. MRI of pituitary gland showed partial empty Sella however since ACTH was high, empty sella was only an incidental finding and not the cause of AI. He is maintained on hydrocortisone 15 mg in the morning and 5 mg in the evening plus fludrocortisone 0.1 mg daily. His fatigue has improved, he is gaining weight and electrolytes are normal. Conclusions: This case report emphasizes the significance of timely diagnosis and management of BAH, which leads to primary AI. BAH is a rare complication following laminectomy. Clinicians should be aware of this possibility and consider it in the differential diagnosis of postoperative abdominal pain and electrolyte abnormalities, especially hyponatremia. Timely recognition and high index of suspicion should prompt empiric glucocorticoid replacement to decrease mortality. Presentation: 6/1/2024

8365 Bilateral Adrenal Hemorrhage Unveiling Adrenal Metastases In A Patient With Retroperitoneal Sarcoma

Abstract Disclosure: R.J. Shah: None. A.C. Goldberg: None. S. Jasim: None. Introduction: Metastatic disease to the adrenal gland is the most commonly occurring malignancy of the adrenal glands. Adrenal hemorrhage (AH) however is a rare but potentially fatal manifestation of malignancy. This case report highlights the unusual presentation of retroperitoneal sarcoma, manifesting as bilateral adrenal hemorrhage in the context of underlying metastases. Case Presentation: A 53-year-old man presented with a 4-week history of fatigue, intermittent abdominal pain radiating to the back, and vomiting. CT revealed bilateral adrenal masses measuring up to 8.5cm on the left side, with Hounsfield units (HU) 27, and 5.9cm on the right, HU 27, consistent with large areas of bilateral adrenal hemorrhage later confirmed on MRI. Biochemical evaluation included ACTH-stimulated cortisol, which was borderline at 17.4mcg/dl (recommended above 18-20mcg/dl), with a significantly elevated ACTH level of 103.8pg/nl (reference range 7.0-63.0pg/ml). Plasma metanephrines, electrolytes, aldosterone, and DHEA-S were normal. Although hemodynamically stable, he was started on prednisone 5mg daily as he was at high risk for primary adrenal insufficiency (AI). He was referred to endocrine surgery and further workup with PET/CT demonstrated a new FDG-avid periaortic retroperitoneal mass, with an interval increase in the size of the adrenal masses and development of hypoattenuating lesions in the kidneys and pancreas favoring aggressive metastatic disease. He underwent biopsy of the retroperitoneal mass, and pathology was consistent with high-grade sarcoma. Oncology started treatment with dexrazoxane and doxorubicin. His adrenal masses remained unchanged in size, and the patient died related to rapid progression of disease. Discussion: Spontaneous bilateral adrenal hemorrhage is rare with a reported incidence of 0.14 to 1.8%. Although most cases have been associated with sepsis, anticoagulation, hematologic disorders and trauma, it is important to maintain a high level of suspicion for underlying adrenal tumors and metastatic disease. AH can be a diagnostic challenge because of its non-specific presentation, and imaging is vital for timely recognition. Patients with bilateral AH should be managed with corticosteroids to avert AI-related fatalities. Presentation: 6/1/2024

Innovative Orbital Periosteum Suturing Technique for Endoscopic Medial Orbital Wall Reconstruction

Abstract Background Advances in endoscopic orbital surgery have sparked discussion regarding reconstructive procedures for medial orbital wall defects following tumor removal. This study describes an innovative orbital periosteal suturing technique that addresses the functional and aesthetic concerns created by orbital surgery. Objective Comprehensive clinical evaluation of a novel orbital periosteal suturing technique for endoscopic medial orbital wall reconstruction. Methods A retrospective chart review identified five patients who underwent endoscopic transnasal resection and subsequent orbital periosteal suturing for reconstruction. The surgical approach involved a binostril transseptal technique to create a broad surgical corridor. The postoperative follow-up was 13.4 ± 1.8 months. Results In the five patients, the mean age was 47.6 ± 13.0 years and the lesions were predominantly distributed on the left side (60%). Reconstruction time with the orbital periosteal suture procedure averaged 47.2 ± 6.6 minutes, employing four to five stitches. No patients experienced short-term complications such as visual acuity defect, new or exacerbated diplopia, or cranial nerve palsy within 2 weeks, and no long-term complications such as enophthalmos or prolonged diplopia were observed. Conclusion Orbital periosteal suturing is an effective and resource-efficient technique for endoscopic reconstruction of the medial orbital wall. Surgeons may consider this method among the available options for orbital reconstruction, representing a novel advancement in the field.

Evaluation the efficacy of microneedling with topical metformin solution compared with microneedling with topical vitamin C solution in treatment of melasma.

Several treatment modalities have been used for the treatment of melasma. Topical metformin is an anti-diabetic drug, which has melanopenic action. Vitamin C acts on melanin by inhibiting the tyrosinase enzyme, thus inhibiting melanogenesis. To compare the efficacy and safety of microneedling combined with topical metformin solution versus microneedling combined with topical vitamin C in the treatment of melasma. A spitted-face interventional comparative on 30 female patients suffering from melasma. The right side of the face was treated with microneedling and topical metformin, while the left side was treated with microneedling and topical vitamin C solution. Hemi-MASI score decreased significantly after treatment from before treatment in both groups P-value < 0.001. The percentage of improvement of Hemi-MASI score metformin group was 48.29%, While with vitamin C group was 37.19%. There was a significant improvement in dermoscopic findings in microneedling with topical metformin than with topical vitamin C group. Microneedling with topical metformin or topical vitamin C solution can be an effective and safe therapeutic option for treating melasma with no significant side effects.

7654 Unusual Case of Lipodystrophy: A Novel Disease Phenotype?

Abstract Disclosure: M. Celik Guler: None. E.D. Frontera: None. K. Hoose: None. M.C. Foss de Freitas: Advisory Board Member; Self; PTC Therapeutics. Speaker; Self; Amryt. L. Douyon: None. E.A. Oral: Advisory Board Member; Self; Amryt, Regeneron Pharmaceuticals. Consulting Fee; Self; Regeneron Pharmaceuticals, Amryt, Third Rock Ventures. Grant Recipient; Self; Regeneron Pharmaceuticals, Amryt. Research Investigator; Self; Novo Nordisk, Ionis Pharmaceuticals Inc., Fractyl, GI Dynamics, Rhythm Pharmaceuticals. Other; Self; Amryt. Background: Lipodystrophy syndromes (LD) are rare disorders characterized by varying degrees of adipose tissue deficiency that can predispose individuals to severe metabolic complications. Although these syndromes are traditionally subclassified based on inheritance patterns and the degree of adipose tissue loss, patients may exhibit highly heterogeneous clinical presentations. In this context, we report a unique case of partial lipodystrophy with an unusual distribution of adipose tissue that likely represents a novel syndrome and challenges conventional phenotypes. Clinical Case: A 60-year-old Puerto Rican female patient with medical history of type 1 diabetes mellitus (DM), obesity, hyperlipidemia, irritable bowel syndrome, asthma, and coronary artery disease was referred to us for unexplained asymmetric distribution of adipose tissue. She had chronic left posterolateral hip pain and lipoatrophy in her left lower extremity. Her medical history showed that she was born approximately 7 lbs., with no evidence of trauma during delivery. Her mother was given an unknown medication for improving circulation to the placenta. She had a morphea like rash on the arms and chest wall more prominent on the left upper body at birth. In addition, a dimple on her hip was noticed by her mother during the early stages of infancy. Despite the normal progression of neurological development (walking/climbing stairs), she always had a very mild limp. Also, her right arm was always 2 inches larger than her left arm. When she gained weight, she also put on more asymmetric weight on the left side of the abdomen and left lower torso. She had been treated with insulin injections since she was diagnosed with diabetes at the age of 11. She never demonstrated any islet cell specific antibodies. She had a normal weight until pregnancy at the age of 27, during which she gained 20 lbs. Her weight continued to increase over time, and the maximum was 212 lbs. Her examination reveals a BMI of 41.46 kg/m² with excess fat in the right arm, mid-section, left thigh, and left mons pubis. Conversely, only the left leg appears to demonstrate specific fat atrophy, with a near-total loss of adipose tissue starting from the mid-gluteal region. The hip MRI result reported moderate osteoarthritis of the left hip. EMG revealed signs of length-dependent sensorimotor axonal polyneuropathy and long duration/large amplitude motor unit potentials isolated only in the left medial gastrocnemius muscle. Triglyceride level was 73 mg/dL, HbA1c level was 6.8%, with an average total insulin dosage of around 43 IU/day. There was no history of pancreatitis due to hypertriglyceridemia. Conclusion: Our case highlights the heterogeneity of the lipodystrophy spectrum with a novel presentation of lipodystrophy. In addition, there may be homeostatic control of deposition of fat to seek symmetry between upper versus lower and right versus left sided depots. Presentation: 6/1/2024

9294 Clinical and Radiological Characterization And Outcomes of Lipid-Poor Adrenal Masses- A Multi-Center Retrospective Study

Abstract Disclosure: V. Balderrama-Brondani: None. R. Al-ward: None. K. Kiseljak-Vassiliades: None. L.M. Fishbein: None. D.A. Kirelik: None. O. Hamidi: None. R. Pishdad: None. H.K. Ghayee: None. M. Sukkari: None. S.S. Bedrose: None. A.H. Hamrahian: None. M.A. Habra: None. Background: Lipid-poor adrenal masses (LPAMs) with pre-contrast radiodensity &amp;gt;10 Hounsfield Units (HU) on computed tomography (CT) represent ∼25% of adrenal tumors. There is limited data about the natural history of LPAMs; therefore, we evaluated a large series of patients with LPAMs to describe the radiological and clinical features and outcomes of these cases. Methods: We conducted a multi-center retrospective cohort study of patients with LPAMs with a baseline diameter of 10-39 mm and derived from 6 institution members of the American-Australian-Asian Adrenal Alliance (A5). We excluded suspected or proven adrenal metastasis, pheochromocytoma, sarcoma, lymphoma, myelolipoma, infiltrative lesions, and adrenal hemorrhage, as well as patients with personal/familial history of genetic predisposition to adrenal neoplasms. The data is presented in percentage and median (range). Results: A total of 242 adrenal masses from 218 patients were evaluated, but only 225 (93%) masses met the inclusion criteria and were analyzed. The age was 58 (23-92), and 61% were women. LPAMs were incidentally discovered in 155 (71.1%) cases, 32 (14.7%) cases were diagnosed due to hormonal overproduction, and 17 (7.8%) due to pain/mass effect. Forty-six (21.1%) patients were on surveillance for a history of extra adrenal malignancy. Masses were unilateral in 89.9% (left side, 57.1%), with size 21 (10-38) mm, with a pre-contrast density of 24 (11-136) HU. Absolute washout was reported in 107 LPAMs and was &amp;gt;60% in 73 (68.2%) cases. The follow-up time was 44.4 (0.9-241) months. Hormonal overproduction developed during the follow-up in 23 (10.5%) cases as follows: cortisol in 15 (6.9%), aldosterone in 4 (1.8%), and sex hormones in 3 (1.4%) cases. LPAM growth rate was 0.03 (-2.18-11.59) cm/year. Seventy-one masses (31.5%) underwent diagnostic procedures (surgery/biopsy) with adrenocortical adenoma (n=37; 52.1%) and adrenocortical carcinoma (ACC) (n=25; 35.2%) being the two most common diagnoses. The tumor growth rate of pathologically confirmed adenomas was 0.03 (-0.30-10.50) cm/year, and of ACC was 1.31 (0.03-11.59) cm/year. A total of 154 (68.4%) LPAMs remained under surveillance at the end of the study, with a follow-up time of 51.8 (6-241) months and a tumor growth rate of 0.02 (-2.18-1.36) cm/year. Forty-five (20.6%) LPAMs decreased by 2 mm (1-13) during the study period. Cases that proved to be ACC had the most significant tumor growth rate over the study (p&amp;lt;0.001). The median time between the initial discovery of LPAM and the surgical resection of ACC cases was 34 (6-128) months. Conclusion: Our study showed that LPAMs carry significant malignant potential, and close long-term follow-up is warranted when surgical resection is not pursued. Prospective studies are critically needed to validate our findings and to establish high-risk molecular, imaging, and biochemical features associated with malignancy. Presentation: 6/2/2024

Evolution from mixed to fixed handedness in mirror-image flowers: insights from adaptive dynamics.

Mirror-image flowers (enantiostyly) involve a form of sexual asymmetry in which a flower's style is deflected either to the left or right side, with a pollinating anther orientated in the opposite direction. This curious floral polymorphism, which was known but not studied by Charles Darwin, occurs in at least 11 unrelated angiosperm families and represents a striking example of adaptive convergence in form and function associated with cross-pollination by insects. In several lineages, dimorphic enantiostyly (one stylar orientation per plant, both forms occurring within populations) has evolved from monomorphic enantiostyly, in which all plants can produce both style orientations. We use a modelling approach to investigate the emergence of dimorphic enantiostyly from monomorphic enantiostyly under gradual evolution. We show using adaptive dynamics that depending on the balance between inbreeding depression following geitonogamy, pollination efficiency and plant density, dimorphism can evolve from an ancestral monomorphic population. In general, the newly emergent dimorphic population is stable against invasion of a monomorphic mutant. However, our model predicts that under certain ecological conditions, e.g., a decline of pollinators, dimorphic enantiostyly may revert to a monomorphic state. We demonstrate using population genetics simulations that the observed evolutionary transitions are possible assuming a plausible genetic architecture.

Diagnostic Accuracy of Ultrasound Imaging and Shear Wave Elastography to Discriminate Patients with Chronic Neck Pain from Asymptomatic Individuals

Objectives: The aim of this study was to determine and compare the capability of several B-mode ultrasound (US) and shear wave elastography (SWE) metrics to differentiate subjects with chronic non-specific neck pain from asymptomatic subjects. Methods: A diagnostic accuracy study recruiting a sample of patients with chronic neck pain and asymptomatic controls was conducted. Data collection included sociodemographic information (i.e., gender, age, height, weight and body mass index), clinical information (pain intensity assessed using the Visual Analogue Scale and pain-related disability using the Neck Disability Index) and B-mode ultrasound and shear wave elastography features of the cervical multifidus muscle (cross-sectional area, perimeter, mean echo intensity, fat infiltration, shear wave speed and Young’s modulus). After analyzing between-group differences for left/right sides, cases and controls, and males and females, the area under the receiver operating characteristic (ROC) curve, the optimal cut-off point, the sensitivity, the specificity, the positive likelihood ratio (LR) and negative LR for each metric were calculated. A total of 316 individuals were recruited in this study (n = 174 cases with neck pain and n = 142 asymptomatic controls). Results: No significant differences (p &gt; 0.05) were found between cases and controls for most variables, except for fatty infiltration, which was significantly higher in chronic neck pain cases (p &lt; 0.001). Gender differences were significant across all US and SWE metrics (all, p &lt; 0.001 except p = 0.015 for fatty infiltrates). A slight asymmetry was observed between the left and right sides for area (p = 0.038). No significant interactions between group, gender and side (all metrics, p &gt; 0.008) were identified. Fatty infiltration was the most effective discriminator, with a ROC value of 0.723, indicating acceptable discrimination. The optimal cut-off point for fatty infiltration was 25.77, with a moderate balance between sensitivity (59.8%) and specificity (20.5%). However, its positive likelihood ratio (LR) of 0.75 suggests limited usefulness in confirming the condition. Conclusions: Fatty infiltration was significantly higher in individuals with chronic idiopathic neck pain compared to those without symptoms, while other muscle metrics were similar between both groups. However, since fat infiltration had moderate diagnostic accuracy and the other metrics showed poor discriminatory power, US cannot be used solely to discriminate patients with idiopathic neck pain.

Radiation dose to the eye of physicians during radio frequency catheter ablation: a small-scale study.

Radio frequency catheter ablation (RFCA), a treatment for arrhythmia, requires a long fluoroscopy time that increases the radiation exposure dose to the physician, particularly to the lens of the eye. It is recommended that a lens-specific dosimeter such as DOSIRIS® is used to measure the dose to the lens. In this study, we investigated whether conventional glass badges can be used as an alternative to lens dosimeters. The doses to the lenses of two physicians (physician A, main operator; physician B, assistant; physician B was further away from the patient than physician A) were measured for 126 RFCA procedures performed over a 6-month period (fluoroscopy rate of 3.0 p/s with use of a ceiling-hanging shield). The cumulative value measured by a lens dosimeter attached to the inside of Pb glasses (0.07-mm dose equivalent) next to the left eye was 4.7mSv for physician A, and 0.8mSv for physician B. The reading on the glass badge worn on the left side of the neck was 4.7mSv for physician A and 1.3mSv for physician B. Lens dosimeter and glass badge values showed a good correlation for the left eye and left neck (r = 0.86, p < 0.01). We show that glass badges may be a viable alternative to lens-equivalent dosimetry when using low-pulse fluoroscopy and a ceiling-hanging shield.

Vertigo as Initial Symptom of Cerebellar Hemorrhage in Adult Woman : A Case Report

Vertigo, difficulty walking, and loss of balance/coordination are among the symptoms of stroke in 50% of stroke cases. Vertigo due to cerebrovascular disease is generally associated with other neurological signs such as cranial nerve abnormalities, hemiparesis, facial weakness, diplopia, hyperesthesia, and Horner's syndrome. A 42-year-old woman came to the emergency department with complaints of dizziness, nausea, and frequent vomiting for the previous 4 hours. The symptoms are also accompanied by a feeling of tingling on the left side of the face, and the left eyelid cannot open optimally. The patient has a history of uncontrolled hypertension. The HINTS test revealed central vertigo, and the patient also found dysdiadochokinesis, ataxia, and dysmethria. A non-contrast head CT scan showed ICH in the left cerebellum with a volume of 6.9 cc. Based on the results of these examinations, the patient was diagnosed with cerebellar hemorrhage. The blood supply to the brainstem, cerebellum, and inner ear comes from the vertebrobasilar vascular system. Blockage or rupture of blood vessels in one of the main branches of this system can cause symptoms of vertigo. Symptoms of vertebrobasilar stroke vary widely and depend on which of the three main circumferential branches is affected; posterior inferior cerebellar artery, anterior inferior cerebellar artery, or superior cerebellar artery. Vertigo in patients who have risk factors for stroke accompanied by other neurological symptoms should be considered for a thorough neurological examination to evaluate the possibility of cerebrovascular disease.

8135 A Rare Case of Late Recurrence of Graves’ Disease Decades After Radioactive Iodine Therapy: Is it Really a Definitive Treatment?

Abstract Disclosure: K.S. Hill: None. R. Osman: None. Graves’ disease (GD) is the most common cause of hyperthyroidism in the US and worldwide. Radioactive iodine (RAI) therapy has excellent success rates in treatment of GD. Studies have demonstrated that RAI successfully treats GD with a single session in the majority of cases. Recurrence after RAI, if it occurs, is most commonly seen in the first year after RAI. However, this is rare particularly in patients who have developed evidence of successful treatment in the form of post-ablative hypothyroidism. Only a few case reports have demonstrated recurrence of GD more than 10 years after treatment of GD with RAI and development of post-ablative hypothyroidism. We report a case of GD recurrence approximately 30 years after ablation. A 69 y/o woman presented for evaluation of hyperthyroidism and newly discovered thyroid nodule. Her history was significant for GD with orbitopathy diagnosed in the early 1990s and treated with RAI. Following the ablation, she developed hypothyroidism and was managed for over 20 years on levothyroxine therapy. In recent years she began to develop symptoms of palpitations and heat intolerance with biochemical evidence of thyrotoxicosis despite reductions in her levothyroxine dose. She also developed recurrence of her orbitopathy, confirmed by ophthalmology. During this time, a neck CT incidentally described an atrophic thyroid gland with a 9 mm soft tissue nodule in the left thyroid bed. Follow up ultrasound showed a 1.1 cm nodule with increased vascularity in the left thyroid bed with an otherwise atrophic gland and no lymphadenopathy. Her levothyroxine was stopped for one month in preparation for a thyroid uptake scan, during which TSH increased to 15 mcU/mL. Scan showed overall severely decreased radioactive iodine uptake of the gland consistent with prior ablation although there was a faint uptake most focally conspicuous on the left side inferiorly. Thyroid stimulating immunoglobulin (TSI) was elevated at 1.35 IU/L (Ref 0.00-0.55). After discussion with the patient, the decision was made for surgical treatment with thyroidectomy. Pathology was benign. She was continued on her prior dose of levothyroxine 75 mcg daily however now with clinical and biochemical evidence of hypothyroidism requiring continued increase in levothyroxine dose to normalize TSH levels. GD is the most common cause of hyperthyroidism and RAI therapy is the most common definitive treatment for GD in the US. Recurrence of GD after ablative hypothyroidism is rare, particularly in the case of late recurrence decades after ablation. Only a few cases are reported in the literature, ours with the longest interval-to-relapse. Recurrence of orbitopathy may be the first clue. Our case highlights the need to continue to monitor clinically for recurrence of Graves’ disease long after RAI use. Presentation: 6/3/2024

Analyzing Optimal Wearable Motion Sensor Placement for Accurate Classification of Fall Directions.

Falls represent a significant risk factor, necessitating accurate classification methods. This study aims to identify the optimal placement of wearable sensors-specifically accelerometers, gyroscopes, and magnetometers-for effective fall-direction classification. Although previous research identified optimal sensor locations for distinguishing falls from non-falls, limited attention has been given to the classification of fall direction across different body regions. This study assesses inertial measurement unit (IMU) sensors placed at 12 distinct body locations to determine the most effective positions for capturing fall-related data. The research was conducted in three phases: first, comparing classifiers across all sensor locations to identify the most effective; second, evaluating performance differences between sensors placed on the left and right sides of the body; and third, exploring the efficacy of combining sensors from the upper and lower body regions. Statistical analyses of the results for the most effective classifier model demonstrate that the support vector machine (SVM) is more effective than other classifiers across all sensor locations, with statistically significant differences in performance. At the same time, the comparison between the left and right sensor locations shows no significant performance differences within the same anatomical areas. Regarding optimal sensor placement, the findings indicate that sensors positioned on the pelvis and upper legs in the lower body, as well as on the shoulder and head in the upper body, were the most effective results for accurate fall-direction classification. The study concludes that the optimal sensor configuration for fall-direction classification involves strategically combining sensors placed on the pelvis, upper legs, and lower legs.

Improvement of stage acoustics in a small circular-shaped recital hall

This paper investigates how stage acoustics can be improved by the installation of on-stage reflectors in a small recital hall with a circular floor plan. The target hall, which is designed as a second floor with a seating capacity of 533, has an average reverberation time of 1.31 seconds in the mid-frequency band at the audience seats when empty, and an average side reflection sound ratio of 0.4. The target hall, assessed as having a circular planar shape with wide left and right sides compared to its depth, is not conducive to performers. Therefore, we measured the stage acoustics according to ISO 3382-1, with a grid spacing of 1 m above the stage. We created a simulation model based on the measurement results. To enhance the stage acoustics, a movable reflector was placed on the stage, and the effective area of the stage surrounded by the reflector was varied and compared through simulation. The results indicated that as the effective area of the stage surrounded by the reflector decreased, STEarly improved. Meanwhile, in the audience, the installation of stage reflectors showed no significant difference in reverberation time or clarity, but the sound pressure level was slightly improved.

Topological robust transmission of elastic waves in heterogeneous phononic crystal plates

Topological insulators possessing robust transmissions in the topologically protected edge have attract increasing attention. Conventionally, the topological edge states are highly concentrated at the edge with limited width, putting restrictions on the potential phononic applications. In this work, a broadened topological interface is reported in the phononic crystal plate with Y-shaped perforated holes, by adding a phononic crystal featuring Dirac points between two phononic crystals with different phases. The band structure of topological edge state together with typical displacement field is presented. Using a line source to excite on the left side of the topological interface, the topological transports of elastic waves are visualized within a broadband frequency range. Moreover, based on the broadened interface including multiple cavities at different spatial locations, the robust wave propagation is investigated by displacement fields. These results give a straightforward platform to explore the elastic wave manipulation in heterostructures for versatile advanced phononic devices.

Gear Classification in Skating Cross-Country Skiing Using Inertial Sensors and Deep Learning.

The aim of this current work is to identify three different gears of cross-country skiing utilizing embedded inertial measurement units and a suitable deep learning model. The cross-country style studied was the skating style during the uphill, which involved three different gears: symmetric gear pushing with poles on both sides (G3) and two asymmetric gears pushing with poles on the right side (G2R) or to the left side (G2L). To monitor the technique, inertial measurement units (IMUs) were affixed to the skis, recording acceleration and Euler angle data during the uphill tests performed by two experienced skiers using the gears under study. The initiation and termination points of the tests were controlled via Bluetooth by a smartphone using a custom application developed with Android Studio. Data were collected on the smartphone and stored on the SD memory cards included in each IMU. Convolutional neural networks combined with long short-term memory were utilized to classify and extract spatio-temporal features. The performance of the model in cross-user evaluations demonstrated an overall accuracy of 90%, and it achieved an accuracy of 98% in the cross-scene evaluations for individual users. These results indicate a promising performance of the developed system in distinguishing between different ski gears within skating styles, providing a valuable tool to enhance ski training and analysis.