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S. Wagle: None. D. Abraham: None. Introduction: Exogenous Cushing syndrome is prevalent due to prolonged exposure to glucocorticoid-containing medications, often found in over-the-counter (OTC) products imported from overseas. We report a patient who developed Cushing’s Syndrome after self-medicating with an agent from Mexico called Artri King. Case Description: A 39-year-old female with a history of non-alcoholic fatty liver disease and arthralgia presented to the emergency department with epigastric pain, melena, 60 lbs weight gain, and bilateral lower leg swelling for 4 months. Her medications included Artri King for arthralgia (2 tablets twice daily for the last four months) and Spironolactone, for leg swelling. Vital signs revealed an elevated blood pressure of 141/108 mmHg and a BMI of 31.28 kg/m². Clinical examination revealed purplish wide striae, bruising, proximal muscle weakness, and peripheral edema. Laboratory testing showed a white blood cell count of 26.73 k/μL, a blood glucose level of 132 mg/dL, HgbA1C 5.9%, a cortisol level of 0.3 µg/dL, and an ACTH level of < 1.5 pg/mL. Her TSH was 3.07 mU/L with a free T4 of 0.6 ng/dL. Imaging studies, including computed tomography and magnetic resonance imaging, revealed a normal adrenal gland. Gastroscopy was unremarkable. An exogenous source for corticosteroids was suspected with suppressed ACTH levels and normal adrenal glands on imaging. Therefore, mass spec testing for corticosteroids was performed. Her serum dexamethasone level of 1076 ng/dL confirmed the diagnosis. Upon inquiry, the patient recalled that her symptoms began after starting the Artri King supplement. Discontinuation of Arti King for two days resulted in a cortisol level of 6.8 µg/dL suggesting rapid recovery of adrenal function. Discussion: Artri King, an OTC supplement marketed for joint pain in Mexico, recommends a dosage of two tablets three times daily. On April 20, 2022, the FDA issued public warnings against its use, as laboratory testing detected undisclosed amounts of dexamethasone and diclofenac, which were not listed on the product label. The presence of surreptitious steroids in supplements should be suspected in patients presenting with exogenous Cushing syndrome. Physicians should review self-administered supplements closely and counsel patients on the risks. Monday, June 3, 2024

Disclosure: N. Raza: None. S. Wagle: None. R.N. Kiani: None. K. Kaput: None. A 63-year-old male with uncontrolled hypertension and Rheumatoid arthritis was admitted for acute psychosis, progressive asthenia, and severe refractory hypokalemia. He was afebrile on admission and blood pressure was 151/99 mmHg. Physical examination lacked typical Cushingoid appearance of moon facies, central obesity, or purple striae. Labs showed a potassium of 1.8 (ref: 3.3-5 mmol/L), HbA1c 6.0% (ref<=5.6 %), 24-hour urinary free cortisol of 9438 (ref<=60.0 ug/d) and random ACTH level of 229 (ref:7.7-63.3pg/ml). The presentation was felt to be consistent with ectopic ACTH dependent Cushing's syndrome. He was treated with ketoconazole 400 mg BID, Deep veinous thrombosis prophylaxis and trimethoprim-sulfamethoxazole daily for PJP prophylaxis. CT chest/abdomen/pelvis was performed and showed a 1.9 cm right middle lobe pulmonary nodule. Past records were reviewed and showed a stable lung nodule from 2020 (2.5 years earlier). Elective lung biopsy was discussed, and the patient was discharged home with plan for outpatient biopsy. Prior to his biopsy, he was readmitted with worsening agitation, hypertension, and extremity edema. After extensive discussion with CT surgery, a decision was made to perform robotic-assisted thoracoscopic resection of the right middle lobe with mediastinal lymph node dissection. Post-surgery his BP improved, agitation resolved, and cortisol level declined to 3.4 (ref: 6.0 - 18.4 ug/dL). Final pathology showed a well differentiated neuroendocrine tumor, low grade. Lymphovascular invasion was present, and one lymph node was positive for tumor. ACTH immunostaining was performed and was also positive. Ectopic ACTH dependent Cushing syndrome represents a rare condition, contributing to 5-20% of Cushing’s cases. Lung carcinoid tumor is one of the major causes of ectopic ACTH syndrome and typically resolves with surgery. Unusual in our case is the stability of the lung lesion prior to his acute decompensation and lymph node positivity. To date, we have not identified a reason for the indolent nature of his tumor. He is currently on a hydrocortisone taper and is actively undergoing treatment planning with our multidisciplinary peer review process. Essential to his management is the coordination of multiple providers, which includes complex medical decision making and treatment decisions. In the future, lung carcinoid should be considered in the differential for persons with difficult to control hypertension and a stable pulmonary nodule Presentation: Thursday, June 15, 2023

Abstract Disclosure: S. Wagle: None. L. Lomo: None. R.L. Dood: None. B. Chadwick: None. D. Abraham: None. Introduction: Struma ovarii is a mono-dermal teratoma of the ovary that is composed of more than >50% of mature thyroid tissue. It accounts for 5% of ovarian teratomas and 1% of ovarian tumors. Although rare, it is seen in women between 40-60 years of age. Most of these tumors are found incidentally. Malignant struma ovarii is even rarer and the mutational profile of these tumors is neither well studied nor understood. We present an uncommon case of malignant struma with NRAS p.Q61R mutation yet with papillary and solid histologic patterns. Case Description: A 53-year-old female with no significant medical or family history presented with acute worsening of chronic lower abdominal pain and irregular menstruation. Her symptoms developed gradually over 6 months. A pelvic and abdominal CT identified a 9.7 cm cystic left ovarian mass without evidence of ascites or peritoneal masses. She underwent laparoscopic left salpingo-oophorectomy. Histopathology examination of the ovarian tumor revealed classical type, well-differentiated papillary, and solid patterns of thyroid carcinoma. The cells revealed nuclear enlargement, irregular nuclei, finely dispersed chromatin, distinct nucleoli, and nuclear grooves. Due to the histologic pattern of classical papillary thyroid cancer, BRAF V600E pyrosequencing was conducted, which revealed wild-type BRAF. This was followed by NGS when NRAS p.Q61R pathogenic variant was identified. Her thyroid ultrasound did not reveal actionable nodules. A TSH (2.17mU/ml) and thyroglobulin (7.6 ng/ml, TG ab neg) levels are consistent with a normal functioning thyroid gland. This patient's tumor findings are unique in that papillary thyroid carcinoma (PTC) and solid growth patterns are typically associated with the BRAF V600E mutation but rarely seen in the context of an RAS mutation. Discussion: Typically, thyroid cancers with papillary and solid variant features are associated with the BRAF V600E mutation. RAS-type tumors have follicular histologic architecture. BRAF and RAS mutations are mutually exclusive in tumors. Our patient’s malignant struma is unique in that it contained a wild-type BRAF and was positive for NRAS p.Q61R mutation. However, the histology was that of papillary and solid patterns. NRAS mutation with papillary histology combination is rare and is seen in 12% of thyroid cancers. The mutational profile of malignant struma ovarii has not been fully understood or studied due to their rarity. Presentation: 6/3/2024

Background: There are limited data regarding the outcome of in-hospital cardiopulmonary resuscitation (CPR) in COVID-19 patients. In this study, we compared the outcomes of in-hospital cardiac arrests (IHCA) before and at the peak of the COVID-19 pandemic at Montefiore Medical Center in the Bronx, New York, United States. We also identified the most common comorbidities associated with poor outcomes in our community. Methods: This was a multi-site, single-center, retrospective, observational study. Inclusion criteria for COVID patients were all confirmed positive cases who had in-hospital cardiac arrest (IHCA) between 1 March 2020 and 30 June 2020. The non-COVID cohort included all cardiac arrest cases who had IHCA in 2019. We excluded all out-of-hospital cardiac arrest (OHCA). We compared actual survival to that predicted by the GO-FAR score, a validated prediction model for determining survival following IHCA. Results: There were 334 cases in 2019 compared to 450 cases during the specified period in 2020. Patients who initially survived cardiac arrest but then had their code statuses changed to do not resuscitate (DNR) were excluded. Groups were similar in terms of sex distribution, and both had an average age of about 66 years. Seventy percent of COVID patients were of Black or Hispanic ethnicity. A shockable rhythm was present in 7% of COVID patients and 17% of non-COVID patients (p < 0.05). COVID patients had higher BMI (30.7 vs. 28.4, p < 0.05), higher prevalence of diabetes mellitus (58% vs. 38%, p < 0.05), and lower incidence of coronary artery disease (22% vs. 35%, p < 0.05). Both groups had almost similar predicted average survival rates based on the GO-FAR score, but only 1.5% of COVID patients survived to discharge compared to 7% of non-COVID patients (p < 0.05). Conclusion: The rate of survival to hospital discharge in COVID-19 patients who suffer IHCA is worse than in non-COVID patients, and lower than that predicted by the GO-FAR score. This finding may help inform our patient population about risk factors associated with high mortality in COVID-19 infection, as well as educate hospitalized patients and healthcare proxies in the setting of code status designation.

The qualitative approach is immensely helpful in policy research as it provides a comprehensive, contextually grounded, and nuanced understanding of policy processes and issues. It is characterized by certain epistemological imperatives that demand the collection of rich, diverse data and a thick description of the context. However, conducting fieldwork to collect data required to fulfill these imperatives poses diverse and stiff challenges, especially for young policy researchers in the Indian context. In this background, this paper argues that, while epistemological principles require qualitative researchers to collect rich and diverse data, the researcher’s social identity and the socio-political ground reality in the field pose significant challenges for young policy researchers in collecting field data. More specifically, the paper discusses the challenges posed by different elements of the researcher’s social identity like economic class, caste, gender, and education. It also discusses the challenges posed by different elements of the socio-political ground reality in the field such as socio-economic inequality, gatekeeping, and by politics played by field-level actors like primary contacts, community leaders, participant groups, and public bureaucrats. It draws from the thematic analysis of fieldwork experiences documented (in the form of fieldnotes and different types of memos) by three Indian researchers (including two females) who were collecting qualitative data for three previous and separate qualitative research projects. This fieldwork was carried out in two different states in India. The discussion in this paper will prove helpful, especially to young qualitative researchers, in planning and executing their fieldwork in developing countries, especially in India.