Multiple Admissions Research Articles

Anemia is a risk factor for rapid eGFR decline in type 2 diabetes.

To investigate the association between anemia and progression of diabetic kidney disease (DKD) in type 2 diabetes. This was a retrospective study. A total of 2570 in-patients with type 2 diabetes hospitalized in Jinan branch of Huashan hospital from January 2013 to October 2017 were included, among whom 526 patients were hospitalized ≥ 2 times with a median follow-up period of 2.75 years. Annual rate of eGFR decline was calculated in patients with multiple admissions. A rate of eGFR decline exceeding -5 ml/min per 1.73 m2 per year was defined as rapid eGFR decline. The prevalence of DKD and clinical characteristics were compared between anemia and non-anemia patients. Correlation analysis was conducted between anemia and clinical parameters. Comparison of clinical features were carried out between rapid eGFR decline and slow eGFR decline groups. The risk factors for rapid DKD progression were analyzed using logistic regression analysis. The prevalence of anemia was 28.2% among the 2570 diabetic patients, while in patients with DKD, the incidence of anemia was 37.8%. Patients with anemia had greater prevalence of DKD, higher levels of urinary albumin-to-creatinine ratio (UACR), serum creatinine, BUN, urine α1-MG, urine β2-MG, urine NAG/Cr, hsCRP, Cystatin C, homocysteine and lower eGFR, as compared to the patients without anemia. Anemia was correlated with age, UACR, eGFR, urinary NAG/Cr, hsCRP and diabetic retinopathy (DR). Logistic regression analysis of 526 patients with type 2 diabetes during the follow-up period showed that anemia was an independent risk factor for rapid eGFR decline. Anemia is associated with worse renal function and is an independent risk factor for rapid eGFR decline in type 2 diabetes.

Ballistic Facial Trauma Reconstruction: Incidence and Practice Patterns in the Civilian Population.

Management of nonfatal ballistic facial trauma is well described in the literature for wounds secondary to military combat. However, there is little literature describing such management in civilian practice. We aimed to describe nonmilitary patients with recent nonfatal facial injuries from ballistic trauma using the California Office of Statewide Health Planning and Development patient database. A retrospective study was performed using the California Office of Statewide Health Planning and Development Ambulatory Surgery and Inpatient datasets. All adults with the International Classification of Diseases, 10th Revision codes of severe nonfatal facial trauma from firearms requiring emergent surgery during 2016-2018 were included. Outcomes assessed include number and type of facial procedures performed, hospital length of stay, number of admissions, timing of definitive management, and lifetime hospitalization costs. A total of 331 traceable patients were identified over this 3-year period. The average age was 35.4 years (SD, 15.2), and 87% were male. The median index admission length of stay was 8 days (interquartile range, 3-15 days). Subsequent readmission was required for 123 (37.2%) patients with 10% mortality in the index admission. Total median charges per patient for all admissions were $257,804 (interquartile range, $105,601-$531,916). A total of 215 patients (65%) had at least 1 facial repair performed. Of all 331 patients, 64.3% underwent musculoskeletal repair (n = 213), 31.4% underwent digestive system repair (n = 104), and 29.6% underwent respiratory system repair (n = 98). The average number of repairs per patient was 2.52 (SD, 3.38), with 35% not having any of the specified International Classification of Diseases, 10th Revision repair codes. A total of 27% of patients had 1 procedure performed, whereas 38% received 2 or more, for an average of 3.87 (SD, 3.5) repairs over the study duration. To our knowledge, this is the first assessment of civilian characteristics of nonfatal ballistic facial trauma in California. Nonfatal facial ballistic trauma results in complex injuries to multiple body systems, requiring long admissions, costly hospital stays, and coordination of care across several surgical specialties. Many patients require a variety of procedures over multiple admissions, highlighting the overall morbidity of these injuries. Future studies will look at how care for these patients differs between various hospitals and geographic regions and whether current civilian management aligns with well-defined military reconstructive protocols for facial ballistic injuries.

Impact of Vaccination on Cost and Course of Hospitalization Associated with COVID-19 Infection.

Examine the impact of vaccination status on hospital cost and course for patients admitted with COVID-19 infection. Retrospective cohort study characterizing vaccinated and unvaccinated individuals hospitalized for COVID-19 between April 2021 to January 2022. Large academic medical center. Patients were included if they were greater than 18 years old, fully vaccinated or unvaccinated against COVID-19, and admitted for COVID-19 infection. 437 consecutively admitted patients for COVID-19 infection met inclusion criteria. Of these, 79 were excluded for unknown or partial vaccination status, transfer from an outside hospital, or multiple COVID-19 related admissions. Overall, 279 (77.9%) unvaccinated patients compared to 79 (22.1%) vaccinated patients were hospitalized with a diagnosis of COVID-19. Average length of stay was significantly lower in the vaccinated group (6.47 days versus 8.92 days, P = 0.03). Vaccinated patients experienced a 70.6% lower risk of ICU admission (OR = 0.29, 95% CI 0.12-0.71, P = 0.006). The unadjusted cost of hospitalization was not found to be statistically significant ($119,630 versus $191,146, P = 0.06). After adjusting for age and comorbidities, vaccinated patients experienced a 26% lower cost of hospitalization compared to unvaccinated patients (P = 0.004). Unvaccinated patients incurred a significantly higher cost of hospitalization per day ($29,425 vs $13,845 P < 0.0001). Unvaccinated patients (n = 118, 42.9%) were more likely than vaccinated patients (n = 16, 20.3%) to require high-flow oxygen or mechanical ventilation (OR = 2.95, 95% CI 1.62-5.38, P = 0.0004). Vaccinated patients experienced a lower cost of hospitalization after adjusting for age and comorbidities and shorter length of stay compared to unvaccinated patients admitted for COVID-19.

Ileal Neuroendocrine Tumour Causing Carcinoid Syndrome in Absence of Hepatic Metastasis

Carcinoid syndrome consists of the classic symptom triad of flushing, diarrhoea, and valvular heart disease. It occurs in the majority of patients with liver metastases. This report presents a 68-year-old female who suffered from chronic diarrhoea with a history of multiple admissions for the same. On evaluation, a Computed Tomography (CT) scan showed a terminal ileal lesion and bulky ovaries. Suspecting Neuroendocrine Tumour (NET) with carcinoid syndrome, a Gallium 68 DOTANOC (DOTA-1-Nal3- octreotide) scan was done which revealed somatostatin receptor expression in enhancing soft tissue lesion in terminal ileum as well as in bilateral adnexa. This confirmed the diagnosis of NET of the ileum and bilateral ovarian metastases. The patient underwent laparoscopic curative resection of the primary tumour along with bilateral oophorectomy. The patient was diagnosed with ileal NET and presented with clinical symptoms of carcinoid syndrome, yet did not have evidence of hepatic metastasis, but instead had bilateral ovarian metastasis which itself is a rare entity.

Yaşlılarda Sağlık Hizmeti İlişkili Enfeksiyonlar: Huzurevlerine Genel Bir Bakış

Healthcare-Associated Infections in the Elderly: An Overview of Nursing Homes Although aging is a natural part of life, the risk of encountering infectious diseases increases with age due to immune senescence and the severity of infections becomes more severe. In addition, infections are sometimes difficult to diagnose because they are atypical and associated with high cost/morbidity/mortality. Infections seen in the elderly may be community-acquired infections, or they may develop as healthcare-associated infections due to the high rate of hospitalization. Healthcare-associated infections are common in vulnerable elderly populations living in long-term care facilities such as nursing homes. Common healthcare-associated infections in nursing home residents include urinary tract infections, respiratory tract infections, skin and soft tissue infections. The risk of healthcare-associated infections is high in nursing homes due to over-prescription of antibiotics, lack of proper sterilization and hygiene management, malnutrition and weakened immunity. In addition, elderly people living in institutions and with multiple hospital admissions are at risk of healthcare-associated infections caused by multidrug-resistant microorganisms, and treatment and management of these infections are difficult. Interventions and guidelines are needed to address the risks affecting the incidence of healthcare-associated infections in nursing homes in Turkey. Keywords: Healthcare-associated infection, long-term care facility, nursing home, elderly

947. Evaluating the Outcomes of Infectious Diseases Consultation on methicillin susceptible Staphylococcus aureus Bacteremia

Abstract Background In 2014, an institutional project was completed assessing outcomes of beta-lactams versus vancomycin in patients with MSSA bacteremia. This research led to the development and implementation of a new standard of care for Staphylococcus aureus bacteremia using a bundle set that included ID consultation. The purpose of this research is to evaluate the impact mandatory ID consultation had on patient outcomes since this bundle set was implemented at our institution. Methods This was a quasi-experimental, single center study of adults with MSSA bacteremia admitted from April 1, 2018 to August 31, 2021. In the instance of patients with multiple admissions with MSSA bacteremia, data from only the first admission was included in the final analysis. Patients were excluded if they had polymicrobial bacteremia or expired within 48 hours of admission. Patients were identified by utilizing reports generated from the pharmacy clinical decision support software of patients with at least one blood culture positive for MSSA. Patients in this list were further screened through manual chart review for inclusion and exclusion criteria. The primary endpoint of this study is inpatient mortality in the setting of MSSA bacteremia with and without an ID consultation. Inpatient mortality was defined as death by any cause during hospital admission. Secondary endpoints included time to bacterial clearance, ID consultation, and mortality. Results Of the patients included, only 42 percent of patients in the pre-bundle set group were treated with MSSA targeted therapy (beta-lactam), in comparison to 86 percent in the post-bundle set group. The difference in secondary outcomes was not statistically significant. For the primary outcome of inpatient all-cause mortality, a 10 percent difference was found between the pre and post-bundle set groups, 18% vs. 8% (p = 0.01). The multivariate regression analysis also confirmed that the presence of an ID consult had a significant relationship with decreased mortality (p = 0.01). Conclusion The all-cause mortality rate of adult patients with MSSA bacteremia significantly decreased after implementation of the Staphylococcus aureus bacteremia bundle set requiring an ID consultation. Disclosures All Authors: No reported disclosures.

1024. Transitions of Care Quality Metrics in Patients Discharged on Parenteral Antimicrobial Therapy in a Large Urban Hospital that Lacks a Formal Outpatient Parenteral Antimicrobial Therapy Program

Abstract Background With the evidence demonstrating the need for antimicrobial stewardship in the transition from inpatient to outpatient intravenous (IV) antibiotic therapy, it is imperative to have effective communication and coordination in a multidisciplinary team. Studies have demonstrated the utility of initiating a formal Outpatient Parenteral Antimicrobial Therapy (OPAT) program. The goal of this study is to assess quality metrics in a sample of patients discharged on IV antibiotics prior to initiation of a pilot OPAT program. Methods This is a retrospective, multicenter chart review of patients admitted to Temple University Health System from 10/1/2020 - 10/31/2021 who were discharged on IV antibiotics. There were no exclusion criteria. Patients with multiple admissions were documented as separate occurrences. Qualitative data were collected on the appropriateness of OPAT indication, pathogens targeted, antibiotics used, performance of infectious diseases (ID) consult, line selected, outcomes, and demographics. The primary endpoint is the percentage of global IV antibiotic prescribing errors (antibiotic, dose, route, frequency, duration, parenteral access device). Results There were 748 total discharges on IV antimicrobials in 705 unique patients. We chose a random sample of 109 discharges. Twenty (18%) had an oral antimicrobial available as an option. Antibiotic selection, dosing, duration, and access were correct 92%, 82%, 64% and 65% respectively (Table 2). ID recommended laboratory monitoring for 44 (40%) patients, of which 8 (18%) were sent to ID clinic; all had abnormal findings. Of the 25 patients who required ID follow-up, 11 had a scheduled ID appointment of which 8 attended. There was no mortality within 30 days from the 8 patients, but 2 were readmitted within 30 days. Overall, 39% patients readmitted within 30 days, 6% had mortality within 30 days and 50% were known to have completed therapy. Conclusion Our study captured a 65% rate of prescribing errors in a sample of 109 patients receiving IV antibiotics at discharge. The findings demonstrate an urgent need for an OPAT program to help with antimicrobial, parenteral access selection, monitoring, and follow-up with ID. By implementing this program, we hope to improve our ID follow-up, lab monitoring, and readmission metrics. Disclosures All Authors: No reported disclosures.

Lupus Enteritis: An Unusual Manifestation of Systemic Lupus Erythematosus

ABSTRACT Though gastrointestinal symptoms are common in Systemic Lupus Erythematosus (SLE), lupus enteritis remains a rare manifestation of the disease. The clinical picture may be non-specific but should be considered in patients with abdominal pain, as this disease entity can progress to intestinal necrosis and perforation if left untreated. This is a case report of a 37-year-old female who had multiple hospital admissions for abdominal pain, was diagnosed with lupus enteritis and showed excellent response to methylprednisolone.

Therapeutic Targeting of EP300/CBP By Bromodomain Inhibition in Acute Myeloid Leukemia

CCS1477 (also known as inobrodib) is a potent and selective inhibitor of the bromodomains of EP300 and CBP, two homologous histone acetyltransferases with critical roles in cellular growth and differentiation. In pre-clinical analyses we found that CCS1477 induced dose-dependent growth inhibition of a wide range of acute myeloid leukemia (AML) cell lines and primary patient samples of diverse molecular subtypes at low nanomolar concentrations. Growth inhibition was predominantly due to cell cycle arrest and differentiation; there was only modest apoptosis. In vivo, in contrast to control mice which all developed short latency AML, all animals with experimentally initiated MLL-AF9 and MLL-AF10 driven AMLs (in a retroviral transduction and transplantation syngeneic model) treated with 30mg/kg daily PO CCS1477 survived to termination of the experiment at 220 days. In subcutaneous xenograft models, there was dose-dependent growth inhibition of MOLM16 AML cell tumours, with 20mg/kg daily for 21 days completely suppressing tumour growth and no tumour regrowth until 14 days following the end of treatment. Mechanistically, we found that 100nM CCS1477 induced rapid and selective depletion of EP300 in particular from MYB binding sites in THP1 AML cells. ChIPseq demonstrated that in steady state the strongest recruitment of EP300 to chromatin in THP1 AML cells was at sites of MYB and CEBPA transcription factor occupancy, although EP300 was also found genome-wide at sites occupied by other factors including RUNX1 and ETS. Following CCS1477 treatment there was, within six hours, selective loss of EP300 at MYB occupied sites, co-localized reduced chromatin accessibility and histone H3K27 acetylation, and stalling of RNA polymerase at subordinate genes with reduced transcription. This was associated with a dose-dependent redistribution of EP300 to alternate sites and up regulation of differentiation genes. In our ongoing phase I/IIa clinical trial investigating the safety and efficacy of CCS1477 in advanced haematological malignancies (NCT04068597), we have observed therapeutically beneficial granulocytic differentiation responses in patients with high-risk myelodysplasia or relapsed AML. For example, a patient with myelodysplasia with excess blasts 2 (MDS-EB2) evolving to AML who had received three cycles of azacitidine without response was treated with CCS1477 50mg PO (once daily, three days/week). Pre-CCS1477 treatment there was profound neutropenia and multiple admissions for sepsis. After CCS1477 treatment the neutrophil count rapidly normalized and, despite a brief admission for splenic infarction in the first week, the patient remained well for 5 months with no infective episodes. Treatment was stopped due to a rising leukocyte count. Similar responses were seen in other patients. In one of these, single cell RNA sequencing of serial blood and bone marrow samples confirmed appearance of mature myeloid cells on CCS1477 treatment and, within the blast population, up regulation of a multilineage differentiation programme and down regulation of a stem cell programme. Reflecting our findings in cell line models, there was also up regulation of genes induced by MYB knockdown and concordant up and down regulation of genes regulated by CEBPA in THP1 AML cells. Finally, we evaluated the activity of CCS1477 in xenograft models in combination with existing standard of care agents. Azacitidine and CCS1477 in particular demonstrated synergistic growth inhibitory activity in the MOLM16 model, as did venetoclax in MOLM16 and MV(4;11) models. These encouraging pre-clinical and early phase clinical findings set the stage for the clinical trial evaluation of CCS1477 in combination with azacitidine and venetoclax.

Tubo-Ovarian Abscess with Actinomyces odontolyticus: Case Report and Brief Review of Literature

Actinomyces odontolyticus is a strictly anaerobic species, a member of the Actinomyces genus and of the commensal flora, especially oral flora, which can trigger severe infections through breaches in healthy tissue or necrotic tissue that are often hard to diagnose clinically and microbiologically. Most infections with this species are pulmonary or pleural, which might hint at a connection with poor dental hygiene, but other locations have been documented. We present a case of a tubo-ovarian abscess with a difficult identification of the etiological agent in a woman with multiple admissions, no significant comorbidities, and a longstanding use of an IUD (intrauterine device). To our knowledge, no previous case of tubo-ovarian abscess with an accurate A. odontolyticus microbiological species identification has been reported so far. This case also highlights the importance of considering an anaerobic species as an etiologic agent in an infectious process concerning a previously damaged tissue and the importance of appropriate harvesting and culturing in the accurate diagnosis of such species.

Abstract 13878: A Case of Severe Tricuspid Regurgitation, Recurrent Ascites, Worsening Renal Function Leading to Hemodialysis Secondary to RV Lead Impingement, Resolved Completely With Lead Extraction

Introduction: 1. In contemporary practice, implantation of Cardiovascular Implantable Electronic Devices (CIED) is associated with low complication rate peri-procedurally. 2. However, in some patients these complications can have high morbidity and mortality; namely pneumothorax, pericardial tamponade, pacemaker syndrome, and rarely tricuspid regurgitation (TR) secondary to lead impingement. 3. TR secondary to RV lead impingement is not uncommon but infrequently lead to severe TR and worsening heart failure symptoms. 4. We present a case of severe TR secondary to RV lead impingement leading to splanchnic congestion and recurrent ascites, worsening renal failure leading to hemodialysis (HD), all of which resolved with lead extraction. Case: A 77-year-old woman with known CAD with prior PTCA, paroxysmal AF, and prior watchman implantation, evaluated in our clinic for severe TR. She had recurrent admissions for ascites needing paracentesis. Her liver function and ultrasound was normal. Her renal function worsened and HD was initiated. ECHO showed normal LVEF, severe TR with RVSP of 74mmHg, and mild RV dysfunction. Pericardial physiology was normal. The lead was noted to be impinging on the septal leaflet, and adherent. Normal pulmonary valve function. Follow up: We proceeded to perform RV lead extraction and implanted a new leadless pacemaker [MICRA-AV, Medtronic Inc]. Her follow up ECHO in 2 weeks showed mild TR and normal RV function. RVSP had dropped significantly to 34mmHg. Surprisingly, her needs for paracentesis came down and by 3 months follow up she did not need paracentesis anymore. Her renal function improved, and her HD needs stopped. Conclusions: 1. CIED implantations are associated with low complication rate (less than 5% in total) in most patient cohorts but in some patients it can be associated with significant complications increasing their morbidity and sometimes mortality. 2. Severe TR is a well-recognized complication of pacemaker implantation. It led to recurrent ascites needing paracentesis, ESRD requiring HD and multiple hospital admissions and thus increasing the morbidity. 3. It is important to recognize the uncommon complications of such commonly used intracardiac devices for electrophysiologists, cardiologists and PCPs.

Obese, non-eosinophilic asthma: frequent exacerbators in a real-world setting

Objective In the UK, asthma deaths are at their highest level this century. Increased recognition of at-risk patients is needed. This study phenotyped frequent asthma exacerbators and used machine learning to predict frequent exacerbators. Methods Patients admitted to a district general hospital with an asthma exacerbation between 1st March 2018 and 1st March 2020 were included. Patients were organized into two groups: “Infrequent Exacerbators” (1 admission in the previous 12 months) and “Frequent Exacerbators” (≥2 admissions in the previous 12 months). Patient data were retrospectively collected from hospital and primary care records. Machine learning models were used to predict frequent exacerbators. Results 200 patients admitted for asthma exacerbations were randomly selected (73% female; mean age 47.8 years). Peripheral eosinophilia was uncommon in either group (21% vs 19%). More frequent exacerbators were being treated with high-dose ICS than infrequent exacerbators (46.5% vs 23.2%; P < 0.001), and frequent exacerbators used more SABA inhalers (10.9 vs 7.40; P = 0.01) in the year preceding the current admission. BMI was raised in both groups (34.2 vs 30.9). Logistic regression was the most accurate machine learning model for predicting frequent exacerbators (AUC = 0.80). Conclusions Patients admitted for asthma are predominately female, obese and non-eosinophilic. Patients who require multiple admissions per year have poorer asthma control at baseline. Machine learning algorithms can predict frequent exacerbators using clinical data available in primary care. Instead of simply increasing the dose of corticosteroids, multidisciplinary management targeting Th2-low inflammation should be considered for these patients.

ODP260 New Type of Autoimmune Diabetes

Abstract Immune checkpoint inhibitors (ICIs) are an emerging therapy that has revolutionized the management of certain cancers. Data on long-term side effects of these drugs are now showing a risk for development of new endocrinopathies. In this case report, a patient with new Type I diabetes (DMI) is discussed. The patient is a 67 year old male with past medical history of metastatic renal cell carcinoma with multiple recurrences of disease. A brief review of the patient's oncologic history revealed multiple surgeries, including complete nephrectomy, multiple drugs, including ICIs, and radiation therapy. Over the course of his treatment, he received Nivolumab (anti-PD1 agent) for 5 cycles with HbA1c increased from 5.4% to 6.9% from pre-treatment to post-treatment, but the HbA1c improved to 5.8% one year after drug cessation. Later he was started on Pembrolizumab (anti-PD1) and has had 10 cycles of therapy to date. Random blood glucose frequently exceeded 200 after start of pembrolizumab therapy. Ipilimumab (anti CTLA-4) was started in combination with pembrolizumab six months later, but it was held after the second cycle due to development of diabetes with HbA1c of 11.1%. He was also found to have persistent, severe hyperglycemia noted during routine bloodwork. Autoimmune DM was confirmed with a positive glutamic acid decarboxylase antibody (GAD65) of 8 nmol/L. Consequently, the patient had multiple hospital admissions for glucose exceeding 400. His condition was exacerbated by the fact that he had difficulty coming to terms with his diagnosis, and he was noncompliant with medication. At that time, the patient stated that he had not done anything wrong and did not understand why this had happened to him. He was resistant to starting therapy and had difficulty understanding insulin dosing, blood glucose monitoring, and the consequences of hyperglycemia/hypoglycemia. After extensive education during a 2 week hospitalization, the patient was eventually place on an appropriate dose of basal-bolus insulin therapy and is currently doing well. It is important to note some emerging challenges to treating this new population of patients with DM1 due to ICI therapy. Firstly, many patients in this scenario live alone and have poor support systems. They have difficulty learning new technology (glucometer, insulin pen, etc.) and self adjusting medication (sliding scale). Older patients can also be more resistance to change in diet and lifestyle. They may have pre-existing insulin resistance that makes initial insulin dosage difficult. Finally, noncompliance is dangerous due to risk of hypoglycemia, diabetic ketoacidosis, and exacerbation of other comorbidities. Clinicians should also consider the patient's psychosocial ability to understand and manage this condition. Presentation: No date and time listed

Prolonged Viral Shedding and Multiple Admissions Due to SARS-CoV-2-Associated Pneumonia in a Patient with Chronic Lymphocytic Leukemia: A Case Report

We describe a case of a patient who experienced recurrent COVID-19 pneumonia over a period of 123 days. Neither remdesivir nor convalescent plasma were temporally associated with viral clearance or increased plasma neutralization capacity. Antibody levels remained low until day 151 and cellular immunity increased overtime with no viral evolution.

PMON38 Severe Refractory Hypoglycemia in a Patient with Metastatic Neuroendocrine Tumor

Abstract Background Neuroendocrine tumors(NETs) differ in origin, location, behavior and response to treatment. In most cases, they secrete hormones or vasoactive substances. Pancreatic NETs (PNETs) are rare tumors and account for 1-2% of all pancreatic tumors. They arise from the endocrine tissue of the pancreas. Fifty to seventy percent of PNETs are not functioning. Functioning tumors can secrete insulin, glucagon, gastrin, vasoactive intestinal peptide depending on their origin. Insulinomas are the most common type of PNETs with an incidence rate of 1-4 per 1000,000 per year. They are usually indolent tumors and rarely malignant. Insulinomas are characterized by fasting hypoglycemia with elevated serum insulin and c-peptide levels. Symptoms can range in severity from confusion, visual changes, palpitations, diaphoresis, and tremulousness to seizures, amnesia or coma. Clinical Case We report a case of a 71 year old male who was referred for an evaluation of ongoing hypoglycemia. He was diagnosed with metastatic carcinoid cancer by fine needle aspiration of the tail of pancreas and liver which showed a well-differentiated neuroendocrine type tumor. A month later, the patient underwent an exploratory laparotomy, pancreatectomy, splenectomy, appendectomy. PNET was identified in the spleen and pancreas. Less than a year later, the neuroendocrine cancer metastasized to the thoracic vertebrae (T8 Biopsy: Positive stains: Pancytokeratin, CD56, Synaptophysin, Chromogranin and Ki-67 [20%]). He received chemotherapy with doxorubicin and streptozocin. He had multiple interventional radiology guided liver chemoembolization. Throughout this time, his hypoglycemia rapidly worsened requiring aggressive medical management. His lab findings (hemoglobin A1C 5.4%, serum glucose 114 mg/dL, c-peptide 26 ng/mL [4.4ng/mL UNL], GFR&amp;gt;60 ml/min/1.73 m2, random insulin levels 123 mIU (24.9 mIU UNL) with serum glucose 108 mg/mL, serum chromogranin A 2616 ng/mL [102 ng/mL UNL]) and clinical progression suggested that his PNETs were insulin producing. He was started on sandostatin and later on diazoxide to control his blood glucose levels. Use of Diazoxide lead to anasarca. Patient was not able to tolerate prolonged fasting due to hypoglycemia that continued to worsen. He required multiple admissions with IV dextrose administration. Later, octreotide was stopped due to concerns of paradoxical hypoglycemia due to glucagon suppression and hypoglycemia initially improved. However, a few weeks later hypoglycemia again worsened and we decided to increase the diazoxide and furosemide. The patient's hypoglycemia continued to progress in frequency and severity and his overall condition continued to deteriorate. The patient therefore chose hospice care and passed away shortly after. Conclusion This is a rare case of rapidly progressing metastatic PNET with severe refractory hypoglycemia in a patient despite treatment with multiple modalities. More research is needed to further characterize PNETs and improve current available management. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

ODP271 Primary Aldosteronism and Primary Hyperparathyroidism: A Report of Dual Endocrine Hypertension

Abstract Background Primary aldosteronism (PA) is one of the common causes of secondary hypertension. Primary hyperparathyroidism (PHPT) is a less common etiology of secondary hypertension. The concomitance of both PA and PHPT is very rare, with a possible bilateral positive feedback loop between the adrenal cortex and the parathyroid gland[1]. Clinical case: A 64-year-old female was referred to the endocrine clinic for secondary hypertension assessment. She was diagnosed with hypertension 30 years earlier, poorly controlled on three antihypertensive medications, nifedipine 90 mg daily, lisinopril 40 mg daily, and atenolol 50 mg daily. She started experiencing muscle cramps two years prior to the referral and was found to be hypokalemic on multiple occasions, with potassium ranging between 2.5 to 3 mmol/L. She also had multiple admissions to the emergency department for hypertensive urgencies within the last year. Family history was positive for poorly controlled hypertension in the patient's mother. Physical examination showed class I obesity with a BMI of 31, but otherwise unremarkable. Workup showed elevated aldosterone concentration of 38 ng/dl and suppressed renin concentration (&amp;lt;1 pg/ml) with an aldosterone/renin ratio of 38. Overnight dexamethasone suppression test was normal (cortisol of 1.5 mcg/dl, suppressed ACTH of 5.5 pg/ml, and appropriately elevated dexamethasone of 324 ng/dl). 24-hour urine metanephrine and normetanephrine levels were normal. Imaging showed bilateral adrenal adenomas of about 13-14 mm in widest diameter, with an average density of 10 Hounsfield units. Adrenal venous sampling revealed hyperfunctioning left adrenal with normal right adrenal. The left adrenal gland was removed laparoscopically, and blood pressure normalized postoperatively on the single antihypertensive agent (lisinopril). Interestingly, during the initial workup, the patient also had elevated calcium of 11 mg/dl and low phosphate at 2.5 mg/dl. In addition, parathyroid hormone (PTH) was elevated at 103 and 95 pg/ml on two occasions, with normal 25-OH vitamin D levels. 24-hoururine calcium was 240mg/dl, and creatinine in urine was 76.4 mg/dl. The calcium creatinine clearance ratio was 2.5%. Diagnosis of primary hyperparathyroidism was made. She had no renal stone, chronic kidney disease, or fractures, with a normal DEXA scan. There was no current indication for parathyroidectomy, and the patient continued to be followed up in the clinic. Clinical lesson: Recent evidence shows cross-talk between the adrenal cortex and parathyroid gland. Our patient may represent such a case, with concomitance of two rare endocrinopathies resulting in difficult-to-control hypertension [1,2]. Thus it is essential to investigate multiple etiologies of secondary hypertension. Reference: Brown JM, Vaidya A. Interactions between adrenal-regulatory and calcium-regulatory hormones in human health. Curr Opin Endocrinol Diabetes Obes . 2014;21(3): 193-201. doi: 10.1097/MED. 0000000000000062 Maniero C, Fassina A, Guzzardo V, et al. Primary hyperparathyroidism with concurrent primary aldosteronism. Hypertension. 2011 Sep;58(3): 341-6. doi: 10.1161/HYPERTENSIONAHA.111.173948. Epub 2011 Aug 8. PMID: 21825220. Presentation: No date and time listed

227 UNSCHEDULED ACUTE HOSPITAL ADMISSIONS FROM A COMMUNITY REHABILITATION TEAM – GERIATRIC GIANTS OR “ACOPIA”?

Abstract Background The Integrated Care Team (founded 2018) provides community rehabilitation in the home for frail older adults. Frail older adults are at increased risk of hospitalisation, and frailty is associated with increased length of stay and mortality. This retrospective cohort study aims to explore the acute hospital admissions of this frail cohort from July 2019 to December 2021. Methods Patients were identified from the integrated care team database who had a discharge destination of “Acute Hospital”. Hospital IT system data and discharge summaries were used to analyse inpatient Length of Stay (LOS), presenting complaints and discharge diagnosis. The study period was from July 2019 to December 2021. Results 67 patients were admitted to hospital during the study period from the care of the integrated care team, accounting for 98 individual hospital admissions. This accounted for 19.8% of discharges from the team during the study period, with 77% of patients discharged to community support. 23.8% of patients (n=16) had multiple admissions, with the majority of these(n=14) admitted twice. The average age of patients was 82.6 years. 58% of admitted patients were female. The longest LOS was 99 days, and shortest less than one day. The average LOS was 12.9 days for the total population. Excluding two outlier stays of 99 and 82 days, the average LOS was 11.27 days. 32% of patients presented with functional decline, 28% with falls, 18% with shortness of breath and 19% with delirium. Infections were diagnosed in 28% of patients, neurological events in 12% and bleeding diagnoses in 11% of patients. 1 patient died during admission. Only 12.2% of stays (n=12) were less than 72 hours in duration. Conclusion This frail patient cohort presented with a range of frailty syndromes and complications of medical comorbidities. The low prevalence of short hospital stays may reflect the ongoing role of the community team supporting patients in the community.

Difficult-to-treat rheumatoid arthritis: Current concept and unsolved problems.

Over the past several decades, the treatment of rheumatoid arthritis (RA) has advanced significantly, and clinical, structural, and functional remission are achievable therapeutic goals. However, a substantial number of patients show resistance to multiple drugs. In particular, patients whose disease activity cannot be controlled despite the use of two or more biological disease-modifying antirheumatic drugs (DMARDs) or targeted synthetic DMARDs (tsDMARDs) with different mechanisms of action (MOA) have recently been referred to as having difficult-to-treat RA (D2T RA). D2T RA is a heterogeneous and multifactorial disease state, and the major problems are uncontrolled disease activity and decreased quality of life, as well as the economic burden due to frequent healthcare utilization and multiple admissions. Since the concept of D2T RA is relatively new and publication regarding D2T RA is limited, the mechanism underlying DMARD inefficacy and which factors form a "difficult-to-treat" state in such patients are not yet fully understood. It is also possible that factors contributing to D2T RA may differ by patient, sex, country, and race. The present Mini Review introduces the current concept and unsolved problems of D2T RA, including the definition, prevalence, and factors contributing to D2T RA. We then discuss the management and therapeutic strategies for D2T RA. Finally, we explore a clinical approach to prevent patients from developing D2T RA.

Anti-titin antibody is associated with more frequent hospitalization to manage thymoma-associated myasthenia gravis.

Background and purposeAnti-titin antibodies are antistriational antibodies associated with thymoma-associated myasthenia gravis (MG). We evaluated whether the patients with anti-titin antibody are more frequently hospitalized to manage thymoma-associated MG than those patients without anti-titin antibody.MethodsPatients with thymoma-associated MG who conducted the serological test for anti-titin antibody were retrospectively included. Disease severity, treatments, MG-related annual hospitalization rate, and MG-related emergency room (ER) visit rate were compared between the patients with anti-titin antibody and those patients without anti-titin antibody. Multivariate analysis was conducted to analyze the association between anti-titin antibody serostatus and multiple admissions (hospitalization or ER visit of ≥2 times).ResultsOf the 64 included patients, 31 (48.4%) patients were positive for anti-titin antibody (titin+ group) and 33 (51.6%) patients were negative for anti-titin antibody (titin– group). Both the annual rate of MG-related hospitalization and ER visit were significantly higher in the titin+ group [0.2 (0.1–0.6) and 0.1 (0–0.2) per year, respectively] than those in the titin– group [0 (0–0.2) and 0 (0–0) per year, p = 0.004 and p = 0.006, respectively]. In multivariate analysis, positive anti-titin antibody was still significantly associated with multiple admissions [odds ratio (OR) 4.11, 95% CI 1.05–16.03] compared to the titin– group as a reference after adjusting for sex, follow-up duration, age at onset, systemic chemotherapy, and the Masaoka staging.ConclusionThe presence of anti-titin antibody is associated with more frequent hospital utilization. Personalized explanation and careful monitoring strategy could be required in patients with thymoma-associated MG with anti-titin antibody for the timely detection of relapses.

New Biomarkers and Their Potential Role in Heart Failure Treatment Optimisation-An African Perspective.

Heart failure is a clinical syndrome resulting from various cardiovascular diseases of different aetiologies and pathophysiology. These varying pathologies involve several complex mechanisms that lead to the activation of the neurohumoral system, inflammation, angiogenesis, apoptosis, fibrosis, and eventually adverse cardiac remodelling associated with a progressive decline in cardiac function. Once a diagnosis is made, the cardiac function has a gradual decline characterised by multiple hospital admissions. It is therefore imperative to identify patients at different stages of the heart failure continuum to better risk stratify and initiate optimal management strategies. Biomarkers may play a role in the diagnosis, prognostication, and monitoring response to treatment. This review discusses the epidemiology of heart failure and biomarkers commonly used in clinical practice such as natriuretic peptides and cardiac troponins. In addition, we provide a brief overview of novel biomarkers and genetic coding and non-coding biomarkers used in the management of patients with heart failure. We also discuss barriers that hinder the clinical application of novel biomarkers. Finally, we appraise the value of polygenic risk scoring, focusing on sub-Saharan Africa.