Buffalo VA Medical Center

BACKGROUNDHypophosphatasia (HPP) is a rare metabolic disorder caused by low tissue-nonspecific alkaline phosphatase (ALP) activity, presenting symptoms from bone demineralization to tooth loss. It affects multiple systems and is diagnosed based on clinical symptoms, radiological findings, and lab tests. This case report emphasizes considering HPP in patients with unexplained bone pain and low ALP levels, especially with underlying osteopenia or osteoporosis. It highlights the importance of genetic testing and counseling for early diagnosis and treatment, aiming to raise clinician awareness.CASE SUMMARYWe present a case of a 65-year-old female patient who was referred to our endocrinology clinic for complaints of generalized bone pain and hypothyroidism. Initial evaluation revealed osteopenia, managed with calcium and vitamin D supplementation. Persistently low ALP levels and elevated vitamin B6 levels led to the diagnosis of HPP, confirmed by genetic testing identifying a pathogenic ALPL gene variant [c.119C>T (p.Ala40Val)]. Despite conservative treatment, her bone density declined, although remaining in the osteopenic range. The Fracture Risk Assessment score indicated a low risk of major osteoporotic and hip fractures, not warranting immediate treatment. Plans are underway to initiate enzyme replacement therapy with asfotase alfa.CONCLUSIONRecognizing HPP is crucial, as early diagnosis and treatment can significantly improve patient outcomes and prevent complications.

This chapter explores the latest advancements in cost optimization from Snowflake, showcasing how the platform continues to evolve to deliver greater value for every dollar spent. The focus is on architectural innovations and intelligent automation that simplify cost governance while enhancing performance. Moving beyond manual tuning and static configurations, Snowflake introduces dynamic, AI-enhanced capabilities that optimize resource use in real time. These developments reflect a strategic shift toward proactive, scalable, and transparent cost management, empowering organizations to align their data operations with financial objectives without compromising agility or performance.

Based on global estimates, almost 10% of adults have diabetes, of whom 40% are estimated to also have chronic kidney disease (CKD). Almost 2 decades ago, treatments targeting the renin‐angiotensin system (RAS) were shown to slow the progression of kidney disease. More recently, studies have reported the additive benefits of antihyperglycaemic sodium‐glucose co‐transporter‐2 inhibitors in combination with RAS inhibitors on both CKD progression and cardiovascular outcomes. However, these recent data also showed that patients continue to progress to kidney failure or die from kidney‐ or cardiovascular‐related causes. Therefore, new agents are needed to address this continuing risk. Overactivation of the mineralocorticoid (MR) receptor contributes to kidney inflammation and fibrosis, suggesting that it is an appropriate treatment target in patients with diabetes and CKD. Novel, selective non‐steroidal MR antagonists are being studied in these patients, and the results of two large recently completed clinical trials have shown that one such treatment, finerenone, significantly reduces CKD progression and cardiovascular events compared with standard of care. This review summarizes the pathogenic mechanisms of CKD in type 2 diabetes and examines the potential benefit of novel disease‐modifying agents that target inflammatory and fibrotic factors in these patients.

This meeting abstract was removed due to the OA licensing requirements of this journal. The full abstract is listed here : https://www.svin.org/files/SVIN_2021_Abstracts_for_Web.pdf

Certain models of cone beam computed tomography (CBCT) image‐guided radiotherapy (IGRT) systems require manually placing the appropriate bowtie filter according to the relevant imaging protocol. Inadvertently using a wrong bowtie filter or no bowtie filter could cause unexpected image artifacts. In this work, CBCT image artifact patterns caused by different bowtie filter placement were evaluated. CBCT images of CT phantoms, that is, a Body Norm phantom, a Catphan® phantom and an anthropomorphic RANDO® phantom, were acquired at a Varian Trilogy® unit with an On‐Board Imager® (OBI) system. Three image acquisition protocols were evaluated. For Standard Head protocol, half‐fan bowtie and no bowtie filter were studied for comparison with the correct full‐fan bowtie acquisition. For Pelvis and Low‐Dose Thorax protocols, full‐fan bowtie and no bowtie were studied for comparison with the correct half‐fan bowtie acquisition. In addition, the possibility of reversed direction half‐fan bowtie was also discussed. All possible scenarios of bowtie filter misplacement caused distinct artifacts regardless of protocols. These artifact patterns are different from the characteristic crescent artifact when correct bowtie filter was placed. Based on the artifact patterns described in this study we recommend reviewing image artifacts at time of image acquisition. If unexpected artifacts appear in the CBCT images, one should verify the correct placement of the bowtie filter and retake the image if necessary. However, it should also be stressed that using a wrong bowtie filter or forgetting to place the bowtie filter can cause increased patient dose. It is always a good practice to verify the bowtie filter placement before acquiring CBCT images for image‐guided radiotherapy.

To our knowledge, REPRISE III is the first large randomized comparison of 2 different transcatheter aortic valve replacement platforms: the mechanically expanded Lotus valve (Boston Scientific) and self-expanding CoreValve (Medtronic). To evaluate outcomes of Lotus vs CoreValve after 2 years. A total of 912 patients with high/extreme risk and severe, symptomatic aortic stenosis enrolled between September 22, 2014, and December 24, 2015, were randomized 2:1 to receive Lotus (607 [66.6%]) or CoreValve (305 [33.4%] at 55 centers in North America, Europe, and Australia. The first 2-year visit occurred on October 17, 2016, and the last was conducted on April 12, 2018. Clinical and echocardiographic assessments are complete through 2 years and will continue annually through 5 years. All-cause mortality and all-cause mortality or disabling stroke at 2 years. Other clinical factors included overall stroke, disabling stroke, repeated procedures, rehospitalization, valve thrombosis, and pacemaker implantation. Echocardiographic analyses included effective orifice area, mean gradient, and paravalvular leaks (PVLs). Of 912 participants, the mean (SD) age was 82.8 (7.3) years, 465 (51%) were women, and the mean (SD) Society of Thoracic Surgeons predicted risk of mortality was 6.8% (4.0%). At 2 years, all-cause death was 21.3% with Lotus vs 22.5% with CoreValve (hazard ratio [HR], 0.94; 95% CI, 0.69-1.26; P = .67) and all-cause mortality or disabling stroke was 22.8% with Lotus and 27.0% with CoreValve (HR, 0.81; 95% CI, 0.61-1.07; P = .14). Overall stroke was 8.4% vs 11.4% (HR, 0.75; 95% CI, 0.48-1.17; P = .21); disabling stroke was more frequent with CoreValve vs Lotus (4.7% Lotus vs 8.6% CoreValve; HR, 0.53; 95% CI, 0.31-0.93; P = .02). More Lotus patients received a new permanent pacemaker (41.7% vs 26.1%; HR, 1.87; 95% CI, 1.41-2.49; P < .01) or had a valve thrombosis (3.0% vs 0.0%; P < .01) compared with CoreValve. More patients who received CoreValve experienced a repeated procedure (0.6% Lotus vs 2.9% CoreValve; HR, 0.19; 95% CI, 0.05-0.70; P < .01), valve migration (0.0% vs 0.7%; P = .05), or embolization (0.0% vs 2.0%; P < .01) than Lotus. Valve areas remained significantly larger and the mean gradient was lower with CoreValve than Lotus (valve area, mean [SD]: Lotus, 1.53 [0.49] cm2 vs CoreValve, 1.76 [0.51] cm2; P < .01; valve gradient, mean [SD]: Lotus, 13.0 [6.7] mm Hg vs 8.1 [3.7] mm Hg; P < .01). Moderate or greater PVL was more frequent with CoreValve (0.3% Lotus vs 3.8% CoreValve; P < .01) at 2 years. Larger improvements in New York Heart Association (NYHA) functional class were observed with Lotus compared with CoreValve (improved by ≥1 NYHA class: Lotus, 338 of 402 [84.1%] vs CoreValve, 143 of 189 [75.7%]; P = .01; improved by ≥2 NYHA classes: 122 of 402 [37.3%] vs 65 of 305 [21.3%]). After 2 years, all-cause mortality rates, mortality or disabling stroke were similar between Lotus and CoreValve. Disabling stroke, functional class, valve migration, and PVL favored the Lotus arm whereas valve hemodynamics, thrombosis, and new pacemaker implantation favored the CoreValve arm. clinicaltrials.gov Identifier: NCT02202434.

BackgroundC. difficile infection (CDI) is an important infectious disease and a reportable hospital metric that results in significant healthcare expenditures. Understanding the epidemiology of CDI is pivotal to the implementation of future preventative measures.MethodsThis was a retrospective data analysis of admitted patients treated at Veteran Health Administration (VHA) hospitals within the United States from 2006 to 2016 using the VHA’s national Corporate Data Warehouse (CDW). All patients with stool testing for C. difficile were identified via laboratory codes associated with C. difficile. CDI is defined as any stool positive laboratory-identified (LabID) event for C. difficile via PCR, Toxin, GDH + (Toxin or PCR), or culture. Hospital-onset healthcare facility-associated (HO-HCFA) CDI is defined as a positive LabID event collected after 48 hours from admission. Incidence is reported as cases per 100,000 admission-days. Recurrent CDI episodes were excluded from incidence analysis. Data were extracted using SQL management studio and analyzed in Excel and JMP.ResultsA total of 389,512 patients were tested for C. difficile. Overall incidence of CDI increased from 2006 (67.6) to 2016 (127.7). This rise in total CDI incidence correlates positively with rise of PCR (P < 0.0001) and 30-days CDI mortality (P < 0.0001). In July 2012, VHA implemented reporting of HO-HCFA CDI. Incidence of HO-HCFA CDI and 30-day CDI mortality increased from 2006 (45.6 and 12.3) to 2013 (69.2 and 17.1) with the rise of PCR (P < 0.001) but decreased from 2013 (69.2 and 17.1) to 2016 (59.9 and 14.1) after implementation of HO-HCFA reporting (P = 0.0058 and P = 0.0068). The median time to testing has also been decreasing from 2006 (78.5 hours) to 2016 (45.5 hours). Amongst all patients with stool positive C. difficile LabID event, the frequency of ICD-9/10 discharge diagnosis code for CDI was 83.3%.ConclusionThe incidence of CDI increased significantly as the use of PCR rose within the VHA. Increased incidence of CDI had a significant impact on mortality. Reporting of HO-HCFA CDI led to a downward trend in the incidence of HO-HCFA CDI and 30-days CDI mortality. Whether this is a true decrease or an improvement in testing programs is unclear as the time to C. difficile testing also declined over the study period. ICD-9/10 discharge diagnosis codes are not representative of all cases of CDI.DisclosuresAll authors: No reported disclosures.

Eichler integrals play an integral part in the modular parametrizations of elliptic curves. In her master’s thesis, Kodgis conjectures several dozen zeros of Eichler integrals for elliptic curves with conductor ≤ 179. In this paper we prove a general theorem which confirms many of these conjectured zeros. We also provide two ways to generate infinite families of elliptic curves with certain zeros of their Eichler integrals.