Basic Metabolic Panel Research Articles

MP68-14 INTRAVENOUS ACETATE IS RENOPROTECTIVE FOLLOWING KIDNEY ISCHEMIA IN A PIG MODEL

You have accessJournal of UrologyCME1 Apr 2023MP68-14 INTRAVENOUS ACETATE IS RENOPROTECTIVE FOLLOWING KIDNEY ISCHEMIA IN A PIG MODEL Hal Kominsky, Jessica Dai, Tara Morgan, Alaina Garbens, Ryan Steinberg, Brett Johnson, and Jeffrey Cadeddu Hal KominskyHal Kominsky More articles by this author , Jessica DaiJessica Dai More articles by this author , Tara MorganTara Morgan More articles by this author , Alaina GarbensAlaina Garbens More articles by this author , Ryan SteinbergRyan Steinberg More articles by this author , Brett JohnsonBrett Johnson More articles by this author , and Jeffrey CadedduJeffrey Cadeddu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The use of medication to avoid ischemia related kidney injury following hilar occlusion has been previously investigated. Renoprotection appears to be conferred by HIF-2A activation which can be stimulated by exogenous acetate administration. The goal of this project was to assess whether administration of acetate in a pig model can negate kidney injury related to ischemia-reperfusion following renal vessel occlusion. METHODS: For this study we selected a porcine single-kidney model. First, a laparoscopic radical nephrectomy was performed, and the pigs were recovered. After seven days, the pigs underwent laparoscopic hilar dissection with 90 minutes of cross clamping on the contralateral kidney to simulate renal vessel occlusion during a partial nephrectomy. We employed block randomization of four experimental groups. Pigs in Group 1 received 150 mEq of sodium acetate intravenously during cross clamping. Group 2 received 0.75 g/kg of oral sodium acetate for three days leading up to the day of cross clamping. Group 3 received no acetate and underwent hilar dissection without any cross clamping. Group 4 also received no acetate and underwent hilar dissection with 90-minute cross clamping. Basic metabolic and complete blood panels were drawn after nephrectomy, immediately before and after cross clamping, at 24 and 72 hours and then 7 days after cross clamping. Serum creatinine was used to evaluate renal function. RESULTS: We performed a total of 16 procedures allocating 4 pigs for each experimental group. All pigs were 6-month-old females with median mass of 34.6 kg. One pig from Group 1 had to be excluded due to renal failure. Figure 1 demonstrates the mean serum creatinine for the experimental groups at each time point following hilar cross clamping. A significant difference in serum creatinine was observed at 90 minutes (p=0.038), 24 hours (p<0.001) and 72 hours (p=0.002) after crossing clamping for the pigs receiving intravenous acetate. The same effect was not observed for the pigs receiving oral acetate. CONCLUSIONS: We observed that the administration of intravenous acetate did confer a significant renoprotective benefit in our ischemia-reperfusion porcine single kidney model. This work is hypothesis generating and could lead to performing a similar study in human subjects undergoing renal hilar occlusion during partial nephrectomy. Source of Funding: Institutional © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e958 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Hal Kominsky More articles by this author Jessica Dai More articles by this author Tara Morgan More articles by this author Alaina Garbens More articles by this author Ryan Steinberg More articles by this author Brett Johnson More articles by this author Jeffrey Cadeddu More articles by this author Expand All Advertisement PDF downloadLoading ...

Lysine-Derived Charge-Altering Releasable Transporters: Targeted Delivery of mRNA and siRNA to the Lungs.

Targeted delivery of nucleic acid therapeutics to the lungs could transform treatment options for pulmonary disease. We have previously developed oligomeric charge-altering releasable transporters (CARTs) for in vivo mRNA transfection and demonstrated their efficacy for use in mRNA-based cancer vaccination and local immunomodulatory therapies against murine tumors. While our previously reported glycine-based CART-mRNA complexes (G-CARTs/mRNA) show selective protein expression in the spleen (mouse, >99%), here, we report a new lysine-derived CART-mRNA complex (K-CART/mRNA) that, without additives or targeting ligands, shows selective protein expression in the lungs (mouse, >90%) following systemic IV administration. We further show that by delivering siRNA using the K-CART, we can significantly decrease expression of a lung-localized reporter protein. Blood chemistry and organ pathology studies demonstrate that K-CARTs are safe and well-tolerated. We report on the new step economical, organocatalytic synthesis (two steps) of functionalized polyesters and oligo-carbonate-co-α-aminoester K-CARTs from simple amino acid and lipid-based monomers. The ability to direct protein expression selectively in the spleen or lungs by simple, modular changes to the CART structure opens fundamentally new opportunities in research and gene therapy.

Empowering medicine residentsto order labs mindfully to improve patient-centered care.

Unnecessary laboratory testing of hospitalized patients is prevalent. We conducted a study focused on "mindful ordering" to decrease unnecessary laboratory ordering within an Internal Medicine residency program. We collected survey data on resident/faculty perceptions of laboratory ordering as well as order information from the electronic medical record (EMR). Interventions focused on resident-identified barriers such as knowledge, EMR, habit and faculty expectations. Interventions were cumulative and included resident/faculty education and EMR optimization. We assessed basic and complete metabolic panels (BMP, CMP) and complete blood counts with and without differential (CBC w/diff, w/o diff). Primary outcomes included: total labs ordered per week, lab and frequency, and resident perception of ordering practices. Secondary outcomes included: length-of stay (LOS) and venipuncture utilization. Survey data demonstrated increased resident perception of both mindful ordering and team discussion. Total labs ordered per week decreased 20% in the first year (1944 to 1500 labs/week). Residents' use of the "one-time draw" option increased; use of "daily" frequency decreased. Trends showed an increase in BMP relative to CMP, and an increase in CBC w/o diff relative to CBC w/diff. These changes were sustained through 127 weeks. There was an approximately 10% decrease in monthly average of patients undergoing venipuncture each day (86.7% to 74.2%). The shifts in laboratory ordering in conjunction with increased discussion about labs suggest a sustained change in resident lab ordering behavior. This study shows the impact of focusing interventions on resident-identified barriers to mindful ordering to create a sustained decrease laboratory orders.

Preoperative Workup of Operative Hip Fracture Patients: A Survey.

Background: There may be disagreement among stakeholders on the need for preoperative cardiac screening for elderly hip fracture patients. Purpose: We sought to assess preoperative workup perceptions among physicians for hip fracture patients across specialties, specifically considering a patient's cardiovascular risk. Methods: A case-based survey was distributed to 50 physicians in each of the 4 departments involved in preoperative patient care: orthopedic surgery (OS), anesthesiology (A), cardiology (C), and hospital medicine (HM). The survey asked about which clinical presentations required a cardiology consult, as well as about further preoperative imaging and laboratory work. Single score intraclass correlation coefficient (ICC) was used to compare agreement. Results: Of the 200 surveys sent out, 33 responses (16.5% response rate) were received. Between all specialties, there was 72% agreement about preoperative cardiology consult need (intraclass correlation coefficient [ICC] = 0.063 or poor) and 71% agreement about preoperative transthoracic echocardiogram (TTE) need (ICC = 0.188 or poor). Within each specialty (A, C, HM, OS) ICCs measuring agreement for the need for cardiology consult were 0.812 (good), 0.561 (moderate), 0.457 (poor), and 0.414 (poor), respectively, and for the need for preoperative TTE were 0.852 (good), 0.441 (poor), 0.848 (good), and 0.188 (poor), respectively. Common preoperative testing requested included complete blood count, basic metabolic panel in all cases, and electrocardiogram with troponins if perioperative acute coronary syndrome symptoms were present. Conclusion: This survey suggests that there may be varying levels of agreement within specialties and poor agreement between specialties on the need for cardiology consultation and preoperative imaging for hip fracture patients. This suggests the need for established, reliable preoperative workup protocols with input from different specialties to streamline preoperative care for patients before hip fracture surgery.

Diarrhea and Coronavirus Disease 2019 Infection.

The global coronavirus disease-2019 (COVID-19) pandemic has caused significant morbidity and mortality, thoroughly affected daily living, and caused severe economic disruption throughout the world. Pulmonary symptoms predominate and account for most of the associated morbidity and mortality. However, extrapulmonary manifestations are common in COVID-19 infections, including gastrointestinal (GI) symptoms, such as diarrhea. Diarrhea affects approximately 10% to 20% of COVID-19 patients. Diarrhea can occasionally be the presenting and only COVID-19 symptom. Diarrhea in COVID-19 subjects is usually acute but is occasionally chronic. It is typically mild-to-moderate and nonbloody. It is usually much less clinically important than pulmonary or potential thrombotic disorders. Occasionally the diarrhea can be profuse and life-threatening. The entry receptor for COVID-19, angiotensin converting enzyme-2, is found throughout the GI tract, especially in the stomach and small intestine, which provides a pathophysiologic basis for local GI infection. COVID-19 virus has been documented in feces and in GI mucosa. Treatment of COVID-19 infection, especially antibiotic therapy, is a common culprit of the diarrhea, but secondary infections including bacteria, especially Clostridioides difficile, are sometimes implicated. Workup for diarrhea in hospitalized patients usually includes routine chemistries; basic metabolic panel; and a complete hemogram; sometimes stool studies, possibly including calprotectin or lactoferrin; and occasionally abdominal CT scan or colonoscopy. Treatment for the diarrhea is intravenous fluid infusion and electrolyte supplementation as necessary, and symptomatic antidiarrheal therapy, including Loperamide, kaolin-pectin, or possible alternatives. Superinfection with C difficile should be treated expeditiously. Diarrhea is prominent in post-COVID-19 (long COVID-19), and is occasionally noted after COVID-19 vaccination. The spectrum of diarrhea in COVID-19 patients is presently reviewed including the pathophysiology, clinical presentation, evaluation, and treatment.

Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review

BackgroundOver-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013...

Male Adolescent With Syncope and Abnormal Chest X-Ray.

A 16-year-old man presented after an episode of syncope and an abnormal chest radiography at an urgent care. He reported chest wall pain after an injury at football practice. On examination, he was awake and alert with reproducible tenderness of the left lateral ribs and a normal cardiac exam. Laboratory study results, including complete blood count, basic metabolic panel, and troponin were at normal levels. The chest radiography (Figure 1) revealed cardiomegaly. After transfer to a tertiary care center, a point-of-care echocardiogram was performed (Figure 2), which prompted pericardiocentesis, and, eventually, magnetic resonance lymphangiography (Figure 3).Figure 2Subxiphoid ultrasound view peering through the liver (†) revealed a large pericardial effusion (#) causing a collapsed right ventricle (∗), surrounded by the pericardium (‡).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Magnetic resonance lymphangiography of the heart (∗) revealed a large, entirely chylous, pericardial effusion (#).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Traumatic chylous pericardial effusion. Pediatric cardiology was consulted, and he ultimately underwent pericardiocentesis and pericardial drain placement. Abundant (>600 mL) milky (chylous) fluid was drained from the pericardium, and he was admitted to investigate the cause. While primary or idiopathic cases exist, chylopericardium is commonly secondary to thoracic duct injury, surgery, neoplasm, or congenital cysts.1Rochefort M.M. Review of chylopericardium.Mediastinum. 2022; 6: 3Crossref PubMed Google Scholar Pericardial fluid triglyceride levels >500 mg/dL is pathognomonic.2Dib C. Tajik A.J. Park S. et al.Chylopericardium in adults: a literature review over the past decade (1996-2006).J Thorac Cardiovasc Surg. 2008; 136: 650-656Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Other findings suggestive of chylopericardium include a milky-white appearance, the cholesterol: triglyceride ratio <1, and fat globules seen with staining.2Dib C. Tajik A.J. Park S. et al.Chylopericardium in adults: a literature review over the past decade (1996-2006).J Thorac Cardiovasc Surg. 2008; 136: 650-656Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Lymphoscintigraphy can confirm an anomalous connection between the thoracic duct and the pericardial space.1Rochefort M.M. Review of chylopericardium.Mediastinum. 2022; 6: 3Crossref PubMed Google Scholar As seen here, in cases of progressive chylous accumulation, patients can develop tamponade physiology requiring a pericardial drain or a window creation.3Akamatsu H. Amano J. Sakamoto T. et al.Primary chylopericardium.Ann Thorac Surg. 1994; 58: 262-266Abstract Full Text PDF PubMed Scopus (65) Google Scholar Management may also include depending surgical thoracic duct obliteration or even diet modifications in very mild chronic cases.4Han Z. Li S. Jing H. et al.Primary idiopathic chylopericardium: a retrospective case series.BMC Surg. 2015; 15: 61Crossref PubMed Scopus (10) Google Scholar This patient underwent lymphatic intervention to obliterate the fistula and was subsequently started on a low-fat diet with minimal recurrence of disease to date.

Calcinosis universalis in systemic sclerosis.

The patient, a 46-year-old woman with a history of systemic sclerosis, interstitial lung disease, and dystrophic calcinosis cutis presented to the emergency department complaining of right thigh pain. Physical examination was notable for a large erythematous, tender, indurated circular area in the medial thigh with many large calcified nodules throughout her thighs. Incision and drainage yielded a small amount of purulent chalky fluid. The patient received antibiotics and was discharged home. Over 5 years, the patient had recurrent soft tissue infections with progressive calcinosis. Her basic metabolic panel was within normal limits (including calcium and phosphorus levels). Computed tomography showed extensive calcification throughout the subcutaneous tissues of the pelvis and bilateral thighs. Some of the calcinosis extended into the intermuscular fascial planes of the adductor and posterior compartment musculature of the bilateral thighs. The patient received nifedipine, mycophenolic acid, rituximab, colchicine, and sodium thiosulfate (topical, intralesional, and intravenous), but her calcinosis continued to progress. Calcinosis is a debilitating condition that occurs in 40% of patients with systemic sclerosis. A long disease duration is associated with progressive calcinosis (1). Thus far, there are no effective treatment options for calcinosis.

A curious case of confusion

A curious case of confusion

224: ALTERNATIVE MANAGEMENT OF DIABETIC KETOACIDOSIS DUE TO REFRACTORY HYPOKALEMIA

Introduction: In a hypoglycemic state, potassium levels are falsely elevated due to potassium shifting extracellularly. Once insulin is initiated, potassium will reverse, returning intracellularly, and leading to a lower potassium level. It is this reason that the standard protocol of diabetic ketoacidosis (DKA) treatment is to not begin insulin until potassium is replenished above a designated level. Below we present a patient with DKA that required treatment outside of standard protocol due to refractory hypokalemia. Description: The patient is a 25-year-old male that presented to the emergency department (ED) with elevated glucose for the past few weeks. He is a type-2 diabetic, controlled with diet and exercise for the last year. Prior to which, he had been on insulin. The only exacerbating factor he can think of is receiving the J&J vaccine around the same time. Other associated symptoms are difficulty breathing, abdominal pain, mild nausea, but no vomiting. In the ED, he was found to be in DKA with labs significant for severe acidosis and critical hypokalemia of 1.6 mmol/L. A central line was placed and potassium repletion began prior to initiating insulin drip, with plan to start insulin once potassium corrected. Following aggressive potassium repletion with up to 40 mEq per hour, it persistently remained below 3 mmol/L. Thus, it was decided to start the patient on the lowest rate of the insulin drip at 0.02 units/kg/hr until his potassium rose above 3.3 mmol/L as per our protocol. While being on the insulin drip, he was also receiving 20 mEq potassium hourly via IV, 40 mEq orally every four hours, with frequent basic metabolic profiles every two hours. The patient remained on the insulin drip for three days until he was finally able to be transitioned to long-acting insulin, 73-hours after admission. Discussion: The treatment of refractory hypokalemia in the setting of DKA is intricate. Insulin, while imperative for the treatment of DKA, can worsen hypokalemia, therefore sequence of medication administration is important in treatment. It is important for providers to recognize and identify the side effects of these treatments. In this case, multidisciplinary rounds were crucial in both monitoring and replacing potassium while on an insulin drip.

The role of Abca7 in late‐onset Alzheimer’s disease animal models

AbstractBackgroundAlzheimer's disease (AD) and other neurodegenerative diseases are typified by a robust microglial‐mediated immune response. Genetic studies have demonstrated that variants in microglial genes are linked to risk for AD. Genome‐wide association studies (GWAS) originally identified ATP‐binding cassette, sub‐family A, member 7 (ABCA7), as a novel risk gene of Alzheimer's disease (AD). Since then, accumulating evidence from in vitro, in vivo, and human‐based studies has extended this association, promoting ABCA7 as one of the most important risk genes of late‐onset AD (LOAD), harboring both common and rare risk variants with relatively large effect on AD risk. Besides associations with disease status, genetic and epigenetic ABCA7 markers show significant correlations with AD endophenotypes; in particular amyloid deposition and brain morphology. In conclusion, human‐based ‐omics studies provide converging evidence of (partial) ABCA7 loss as an AD pathomechanism.MethodTo investigate the impact of Abca7 gene expression on microglia biology and disease pathology, we have generated Abca7A1527G mice on an APOE4.Trem2R47H (LOAD1) and APOE4.Trem2R47H.hAß (LOAD2) background. Cohorts of mice were established at JAX and IU and aged to either 4 and 12 months (LOAD1) or 4‐, 12‐, 18‐, and 24‐month. In vivo behavior and wellness assays included continuous activity monitoring, frailty assessment, open field, grip strength, spontaneous alternation, rotarod, delayed spatial novelty, episodic memory, and general health were completed as well as MRI and PET studies. Post‐mortem studies included blood chemistry, immunohistochemistry, and molecular studies. Studies of transcriptomics and proteomics were also completed on brain tissue.ResultCorrelation of transcriptional profiling with human AMP‐AD modules determined individual and synergistic effects with genetic risk factors. At 12 months of age, LOAD1.Abca7A1527G mice show similar correlations to LOAD in Consensus Cluster B (immune system), Consensus Cluster D (cell cycle), and Consensus Cluster E (organelle biogenesis). Neuropathology analysis in brain tissue is in progress, as are cytokine panels in brain homogenates and plasma of LOAD2. Abca7A1527G mice.ConclusionOur findings provide evidence that Abca7 plays an important role in LOAD and the addition of Abca7A1527G to a sensitized LOAD model (LOAD1 and LOAD2) more closely align phenotypes in the mouse to outcomes observed in human AD.

Severe Hypertriglyceridemia Causing Pseudo-acidosis: A Case Report

Pseudo hypobicarbonatemia is a rare phenomenon associated with spuriously low bicarbonate levels in the presence of elevated triglycerides (TG). TG’s interfere with commonly used enzymatic assays in basic metabolic panel (BMP), giving falsely low bicarbonate levels. It adds to the diagnostic dilemma and possible extensive workup to identify the cause. Previous case reports have used plasmapheresis in these settings. We report the successful use of insulin infusion in managing a case of pseudo-acidosis secondary to severely high TG levels. Our patient was a 53-year-old female who presented with complaints of progressive fatigue. Her bicarbonate was 5 mmol/L on workup, anion gap was 30 mmol/L, with elevated TG levels (5904 mg/dL). Arterial blood gas analysis showed normal pH (7.32) and normal calculated bicarbonate (22.8 mmol/L). Insulin infusion was started along with adding fenofibrate and atorvastatin. TG levels decreased progressively to 509 mg/dL with an associated normalization of bicarbonate levels and anion-gap acidosis on BMP. The patient was discharged on day 8 of her hospital stay. Hyper TG can lead to pseudo hypobicarbonatemia, presenting as pseudo anion gap metabolic acidosis. It is essential to correlate the lab findings in the perspective of clinical findings to avoid over-testing and clinical misdiagnosis. In addition, these patients can be managed safely with insulin infusion in resource-limited settings.

Detecting Exogenous Contamination of Clinical Blood Samples with Crystalloid Solutions: A Data Driven Approach to Derive and Validate Delta Checks

Abstract Pre-analytical error may occur when collecting blood samples from intravenous (IV) lines. Blood samples can be inadvertently diluted by exogenous solutions if an insufficient amount of blood is discarded prior to collection. Rules built in the laboratory information system or middleware can be used to alert laboratory staff to specimens that require co-investigation with the clinical team to determine if sample dilution is possible or likely. Currently, however, there is a lack of literature to guide laboratorians on how to define quality rules of this nature, particularly for detecting subtle, rather than gross contamination by commonly administered IV-fluids. Accordingly, the primary objective of this study is to derive sensitive and specific, multivariate delta checks to detect more subtle blood sample contamination by commonly used crystalloid solutions. To derive the rules, we began with in vitro experiments by spiking increasing volumes of major IV-fluids (normal saline (NS), lactated ringers (LR), and 5% dextrose (D5W)) into clinical blood samples that were collected from healthy donors (n=3). Crystalloid solutions were serially spiked into blood samples at 10% (solution:sample) increments for NS and LR from 10% up to 90%, and in 5% increments for D5W, up to 50%. Basic metabolic panel (BMP) analytes were measured and compared between neat and contrived samples. All testing was performed on Roche Cobas 8000 chemistry auto-analyzers. Based on in vitro data, we derived multivariate delta checks using analytes in a BMP that would reflect 10-40% contamination by a given fluid. We then performed a retrospective data analysis on more than 28 thousand, serially collected BMP results to identify samples that were flagged by these rules. Chart review was then performed to identify EHR-based evidence of temporally associated administration of crystalloid solutions through a peripheral IV access line. Increasing sample dilution from the in vitro study showed significant changes in several BMP analytes across all fluid types. With respect to NS, the most significant changes relative to baseline were observed with potassium, calcium, and chloride, while for LR, the most significant changes relative to baseline were observed with glucose, bicarbonate, and calcium. For D5W, significant changes were observed with glucose, calcium, chloride and sodium. Accordingly, delta check rules were implemented using relative changes of the aforementioned analytes. On chart review, we found 80-100% of flagged samples came from patients with administration of that given fluid in the last 12-24 hours. The results from this study support delta checks that consider multiple analytes, and fluid-specific bias profiles, as this may provide a more sensitive and specific approach to detecting contamination of clinical blood samples by crystalloid solutions. Further evaluation using retrospective data analysis will be used to validate these rules sensitivity and specificity followed by prospective testing before implementation.

Machine Learning Models Can Accurately Detect Crystalloid Contamination of Basic Metabolic Panels

Abstract A common cause of erroneous laboratory results is preanalytical contamination of samples with intravenous crystalloids. Rules-based approaches, such as delta checks or feasibility cut-offs, can detect these errors, but rely on prior laboratory results and lack sensitivity. In this study, we aimed to improve the detection of crystalloid contamination using two machine learning workflows for the detection of contamination by the four most common crystalloids; normal saline (NS), lactated Ringer’s (LR), and their dextrose-containing counterparts (D5NS and D5LR). First, we employed a semi-supervised approach using manifold approximation and contrastive learning. To do this, we aggregated five years' worth of basic metabolic panel results (n = 67 million), then simulated contaminated samples by mixing random subsets of samples in silico with the crystalloid solutions at different ratios. The dataset was partitioned into a 70:30 split between training and testing sets with five-fold cross-validation. An autoencoder was trained to create an embedding of the data by minimizing the triplet loss. This embedding was then projected onto a two-dimensional manifold. When the four crystalloid solutions and the independent test set were mapped to the manifold, decision boundaries were drawn based on the threshold that maximized the F1 statistic, and labels were assigned. This method detected the 10% in silico mixtures with an area under the receiver operating characteristic curve (AUC) of 0.97, 0.94, 0.99, and 0.99 for NS, LR, D5NS, and D5LR respectively. Next, we evaluated a fully-supervised approach by training and validating Random Forest and XGBoost models using the same training and testing sets as above. Both models performed well, with XGBoost slightly outperforming Random Forest. The XGBoost model demonstrated AUCs of 0.992, 0.990, 0.998, and 0.996 for the NS, LR, D5NS, and D5LR mixtures. This high-level performance was maintained even as the proportion of mixed samples in the dataset was decreased from 50% to 1% to more accurately reflect real-world contamination rates. For NS and LR, the variables with the highest relative importance were calcium and chloride. For their D5 counterparts, glucose and calcium were most important. Creatinine and blood urea nitrogen were the least important variables in both approaches. Overall, the fully-supervised learning approach outperformed that of the contrastive embeddings for the specific task of identifying contamination from pre-defined crystalloids. One advantage of the semi-supervised approach is that it could be adapted to identify outliers that are not pre-defined. However, considering the relative ease of translating tree-based models into practice, we conclude that our XGBoost model offers the most promising solution and plan to prospectively validate this model for real-time detection of sample contamination.

Abstract 12122: Five-Year Serial Measurement of the Intermountain Mortality Risk Score for Population Health Assessment Reveals Personalized Temporal Trajectories of Differential Longevity Over Two Decades

Introduction: Health, wellness, and healthcare are most effectively and efficiently managed when health status is quantitatively measured. The Intermountain Mortality Risk Score (IMRS) is a well-validated low-cost decision tool calculated from the complete blood count and basic metabolic profile that can be electronically deployed to inform clinician or patient actions. This study evaluated if 3 serial IMRS measurements improved mortality prediction. Methods: In 119,379 Intermountain Healthcare outpatients, inpatients, and emergency patients, baseline (BL) IMRS was calculated in 1999-2005. Of those, the following were excluded: 22,678 who died prior to having 3 IMRS measurements and 38,228 survivors who at 5 years (y) post-BL did not have 3 IMRS. In the study cohort of 58,473 patients, a 1 st follow-up (1F) IMRS was available 1.49±0.79 y post-BL (range 1-4 y), and a 2 nd follow-up (2F) IMRS at 3.75±0.80 y post-BL (range 2-5 y). Patients had 13.4±1.7 y of follow-up after 2F (range: 9.3-18.7 y), with total follow-up post-BL of 17.2±1.5 y (range: 14.3-20.7 y). Results: Overall, 26,693 patients died (45.7%) after 2F. In females, IMRS for decedents vs. survivors was, respectively, 11.3±3.9 vs 6.3±4.0 at BL, 11.1±3.9 vs 5.7±4.0 at 1F, and 12.2±4.2 vs 6.1±4.0 at 2F; differences in males were similar to those results (all p&lt;0.001). Relative risks for IMRS categories are shown in the Table. C-statistics for females were c= 0.815, 0.834, 0.858 for BL, 1F, and 2F, with 0.872 for a sum of the 3 IMRS (results were similar for males, with absolute c 0.06-0.08 lower). Conclusions: IMRS predicted substantial risk differences at each of 3 timepoints, but the IMRS trajectory (including declines in IMRS) revealed by the sequence of IMRS measurements better personalized risk assessment. When risk level and direction are considered together, critical junctures in a person’s health journey may be revealed, empowering earlier or more intensive prevention, diagnostic testing, and interventions.

Abstract 11625: To Cool or Not to Cool for Brugada Syndrome

Brugada syndrome (BrS) is an autosomal dominant genetic disorder, characterized by abnormal findings on the electrocardiogram (ECG) in conjunction with an increased risk of ventricular tachycardia (VT) and sudden cardiac death. Triggers of the ECG pattern and VT in BrS include fevers, drugs, and electrolyte abnormalities. This case reports a unique treatment approach of targeted temperature management (TTM) to treat persistent fevers and VT secondary to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a patient with BrS. We report the case of a 23 year old male with history of BrS with an intracardiac defibrillator (ICD) who presented to the hospital with chest pain and a runny nose. Vital signs upon admission were notable for temperature of 38.2 o C, heart rate of 155 beats/minute and blood pressure of 134/110 mmHG. Laboratory values on admission revealed a normal complete blood count, a normal basic metabolic panel, an elevated c-reactive protein (CRP) of 19.1, and PCR confirmed SARS-CoV-2 infection, with a cycle threshold value of 16.4. ECG revealed a type 2 Brugada pattern. Interrogation of his ICD revealed 28 device shocks on the morning of admission, with each episode beginning with a premature ventricular contraction inciting polymorphic VT. His transthoracic echocardiogram (TTE) discovered a newly reduced ejection fraction of 25% with global hypokinesis. Persistent VT prompted intubation and sedation with propofol. Repeat SARS-CoV-2 inflammatory markers revealed a rising CRP of 244. Therapies included acetaminophen around the clock and remdesivir and dexamethasone to target COVID-19. During the first two days in the cardiac intensive care unit (CICU), fevers persisted with Brugada pattern on ECG. Given the potential for recurrent VT, targeted TTM was initiated using the Arctic Sun external cooling device to maintain normothermia to 37 o C. After 5 days of no VT, fever curve, Brugada pattern, and inflammatory markers improved. TTM was discontinued, COVID-19 therapies were completed, and he was extubated. His cardiac function normalized on repeat TTE and he was discharged home. We report a unique case of TTM use in a patient with BrS with VT secondary to infection with COVID-19, as a way to decrease fevers and prevent further triggering of VT.

Abstract 15725: Non Existing Pacemaker: A Complication of Kyphoplasty

Introduction: Diagnosis of cement emboli remains challenging due to heterogenicity of diagnostic findings. We describe a case of cement embolism interpreted as abandoned pacemaker leads. Case description: A 76-year-old female underwent lumbar kyphoplasty. In the post-anesthesia care unit, she developed multiple asymptomatic episodes of non-sustained ventricular tachycardia. Her lab work including basic metabolic panel, electrolytes, and troponin was unremarkable. A transthoracic echocardiogram (TTE) revealed intracardiac foreign body interpreted as abandoned pacemaker wires originating at the superior vena cava with one terminating in the right ventricular (RV) apex and the other in the right atrial (RA) appendage (Figure 1). Chest computer tomography (CT) confirmed intracardiac pacemaker wires. The patient denied any history of pacemaker placement. TTE and CT images were reviewed again with multiple other opinions stating that the foreign body represented dense cement from the vertebral body. It exited through a paravertebral vein into the inferior vena cava making its way to the right heart (Figure 2). Coronary angiography confirmed an elongated cement embolus. The patient underwent cement removal through sternotomy. Conclusions: Diagnosis of cement embolism may remain challenging as it can mimic any foreign bodies including pacemaker wires. Suspicion for the diagnosis should remain high in any patient who underwent kyphoplasty and developed cardiac arrhythmias or other cardiac symptoms. Image 1. A - Pacemaker lead passing through RA to the RV. Image 2. A- cement material in the right heart. B- Cement extravasating through right paravertebral vein.

ODP352 Steroid-sparing immunosuppressive therapy controls refractory headaches due to lymphocytic hypophysitis: a case report

Abstract Background Systemic glucocorticoid therapy has been used to control headaches associated with lymphocytic hypophysitis (LH), a rare autoimmune inflammation of the pituitary gland and stalk. Steroid-sparing immunosuppressive therapies, like mycophenolate mofetil (MM), have proven to be effective for patients with many systemic inflammatory and rheumatological conditions. However, the safety and efficacy of steroid-sparing immunosuppressive therapies for LH has not been studied. Clinical Case Here we report a case of a 31-year-old male who presented with worsening headache, fatigue, polyuria, insomnia, low libido, and decreased appetite. His laboratory results were consistent with central diabetes insipidus (DI), central hypothyroidism, central adrenal insufficiency, and hypogonadotropic hypogonadism without evidence of growth hormone deficiency. Initial pituitary MRI revealed pituitary enlargement and thickening of the stalk. He was started on desmopressin, levothyroxine, testosterone cypionate, and physiologic glucocorticoid replacement with prednisone 5mg daily. He continued to endorse incapacitating occipital headaches not relieved by ibuprofen, topiramate, gabapentin, amitriptyline, sumatriptan, or rizatriptan, and only temporary relieved by occipital nerve blocks. A pituitary biopsy confirmed the diagnosis of LH. Given his persistent, debilitating headaches, prednisone was increased to supraphysiologic doses. Headaches resolved on prednisone 40mg daily but recurred two months after tapering down to prednisone 5mg daily. Pituitary MRI after 4 months revealed a mild interval increase in enhancement and thickening of the pituitary stalk. Prednisone was increased to 20mg daily, and he was started on MM for progressive inflammation. Prednisone was tapered down to 5mg daily over the course of 3 months as MM dose was increased to 1000mg twice a day. Headaches completely resolved. After 4 months of MM therapy, pituitary MRI showed decrease in size of pituitary stalk thickening and pituitary, consistent with treatment effect. After 6 months of MM therapy, MRI brain showed further decrease in pituitary size and resolution of pituitary stalk thickening. He did not experience any adverse effect on MM. Serial complete blood counts, liver function tests, and basic metabolic panels were normal. Two years after diagnosis and one year on MM therapy, his DI resolved, his adrenal insufficiency was well managed with prednisone 4mg daily, he was euthyroid on levothyroxine 75mcg daily, and his hypogonadism was treated adequately with testosterone cypionate 50mg weekly with improved libido and energy. Conclusion MM was effective in treating intractable headaches caused by biopsy-proven LH. Radiologic signs of improvement in pituitary inflammation coincided with patient's report of headache relief and initiation of MM, without concurrent use of supraphysiologic glucocorticoids. Treatment was well-tolerated with no reported adverse effect. Steroid-sparing immunosuppressive therapy like MM may be considered as a therapy for LH, particularly in patients who depend on prolonged courses of supraphysiologic glucocorticoid treatment to alleviate symptoms. Presentation: No date and time listed

PMON81 A Case of Hypophysitis Associated With SARS-CoV2 Vaccination

Abstract Objective Although SARS-CoV2 vaccines have been developed with multiple novel technologies and rapidly disseminated worldwide, the full profile of adverse effects has not been known. Recently, there are sporadic but increasing reports of endocrinopathies in relation to SARS-CoV2 vaccination. Here, we report a rare case of hypophysitis with acute onset of diabetes insipidus after SARS-CoV2 vaccination. Case Report A 48-year-old female who had been in her usual state of health until she received the first SARS-CoV2 vaccine. Two days after the vaccination, she started to have flu-like symptoms including severe headache and myalgia as well as persistent headache, polydipsia and polyuria. On presentation, her vital signs were stable, with her pulse being 81 bpm, BP: 122/84 mm Hg, temperature: 98.6F. Her physical examination was unremarkable. Laboratory evaluation revealed normal values of the basic metabolic panel including sodium level of 142 mmol/L and normal complete blood count. Due to her prolonged and worsening headache, she underwent a brain MRI which revealed a 4 mm round shape of thickening pituitary stalk and partial empty sella. The polydipsia, polyuria, and the thickening of the pituitary stalk led to further pituitary work-up. She underwent the overnight water deprivation test followed by the desmopressin challenge test. Her overnight water deprivation test revealed hypernatremia (Na 147 mmol/L), elevated serum osmolarity (309 mmol/kg), and low urinary osmolarity (83 mmol/kg) which were compatible with diabetes insipidus. Her IGF1 level revealed low normal range (66 ng/mL). Her 250 mcg cosyntropin test showed appropriate response without adrenal insufficiency. DDAVP was started. 3 months after the vaccination, her symptoms have partially improved, and on repeating the MRI brain she has persistent pituitary stalk thickening. Discussion We report a rare case of diabetes insipidus from hypophysitis associated with SARS-CoV2 vaccine. Mechanisms of SARS-CoV2 vaccination-associated endocrinopathy is unknown. From our literature search, we found increasing numbers of the cases of endocrinopathy reported after the SARS- CoV2 vaccination. The thyroid seems the most frequently reported endocrine organ (83%), followed by the pituitary (11%) and adrenal (6%). Average onset is 1-5 days after the vaccinations and reported with all types of SARS-CoV2 vaccines. More mid-age (average age 46) female (78%) cases have been reported. Although associations are not confirmed, endocrinopathies may be underestimated in the post vaccinated population. Further studies are warranted to better understand SARS-CoV2 vaccinations and potential associations of endocrinopathy. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

PMON112 Primary Pituitary Lymphoma Presenting as Apoplexy

Abstract Background Primary pituitary lymphoma (PPL) in immunocompetent individuals represents a distinct and rare clinical entity. Clinical Case A 49-year-old menopausal woman with past medical history of hypertension and obesity who presented to the emergency room with sudden onset loss of vision in her right eye with blurriness on the left. She had been having intermittent headaches and flu-like symptoms over the 2 days preceding her presentation. Her BP was 179/116 mmHg, initial basic metabolic profile was normal, and head CT showed hemorrhage into a bilobed sellar and suprasellar mass measuring 2.2×2.2×3.3 cm. On ophthalmic exam, the right eye showed near-complete visual field loss with some residual island of vision superotemporally while left eye showed temporal hemianopsia. Initial endocrine workup was notable for a normal cortisol 15.9 (ref 2-20) ug/dL and normal prolactin; low-normal TSH 0.73 (ref 0.2-4.2) uIU/mL; low free T4 0.3 (ref 0.9-1.7) ng/dL; low FSH, LH, and IGF-1. She received a pituitary MRI showing hemorrhagic pituitary macroadenoma with significant upward bowing of the optic chiasm and infiltration into the cavernous sinuses. The patient developed diabetes insipidus (DI) before being taken to the operating room for transsphenoidal surgery with debulking and biopsy. Postoperatively and while waiting for pathology results, she developed panhypopituitarism and was being treated with hydrocortisone, levothyroxine, and desmopressin. Her pathology was consistent with diffuse large B-cell lymphoma (DLBCL) of non-germinal center type. She had a complete hematologic workup including whole body PET-CT showing sellar and suprasellar fluorodeoxyglucose avid disease without evidence of disease elsewhere in the head, neck, and torso which confirmed the diagnosis of PPL. The patient was started on chemotherapy using R-CHOP (rituximab, cyclophosphamide, hydroxyadriamycine, vincristine, and prednisone) with high-dose methotrexate. Following the first chemotherapy treatment cycle, she had a modest improvement in her vision; however, her DI was permanent. Conclusion This case demonstrates that PPL can present with pituitary apoplexy and can result in panhypopituitarism and permanent DI. Individuals with this condition require a multidisciplinary care team including endocrinology, neurosurgery, hematology, and ophthalmology. References A Giustina, M Gola, M Doga, E A Rosei. Primary Lymphoma of the Pituitary: An Emerging Clinical Entity. JCEM. 2001 Oct;86(10): 4567-75.A Tarabay, G Cossu, M Berhouma, M Levivier, R T Daniel, M Messerer. Primary pituitary lymphoma: an update of the literature. J Neurooncol. 2016 Dec;130(3): 383-395. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.