Fresno VA Medical Center

The role of coronary computed tomography angiography (CCTA) in diagnostic cardiology is steadily increasing. Normal CCTAs successfully reclassify patients to a low-to-intermediate risk category with marked reduction in cardiovascular events. However, hepatic steatosis has been associated with adverse cardiovascular events and can be routinely evaluated on non-contrast CCTAs. The prevalence of hepatic steatosis in the setting of normal CCTAs is not known and may be of clinical significance. We conducted a retrospective, single-center analysis to evaluate for the presence and incidence of hepatic steatosis in the setting of normal CCTAs. Non-contrast images were used to identify/measure the presence or absence of hepatic steatosis. The presence of hepatic steatosis was defined based on attenuation measurements in Hounsfield units (HU), by comparing the liver and spleen. Of 297 patients screened, a cohort of 99 patients were identified with a coronary calcium score of zero. Ten patients (10%) were found to have non-calcified plaque on CCTAand were excluded from the study population. Of the remaining 89 patients, 13 patients (14%) were found to have evidence of hepatic steatosis. Patients with normal CCTAs are often reassured, supported by data predicting an improved prognosis with low rates of cardiovascular events. Wepropose that evaluating and identifying patients with underlying hepatic steatosis, a known associated marker of atherosclerosis, even in patients with "normal"CCTAs is important, as this correlates with higher cardiovascular risk.

Disclosure: M.P. Reyes: None. P. Ginier: None. M. Koteles: None.Introduction: Iodine-induced hyperthyroidism (Jod-Basedow phenomenon) occurs when excessive iodine triggers thyrotoxicosis in individuals with nodular thyroid disease. Repeated iodinated contrast exposure can cause severe complications. Identifying high-risk patients and monitoring thyroid function post-contrast exposure is essential. Clinical Case: A 75-year-old male with no prior thyroid disease underwent two iodinated contrast-enhanced CT scans: an abdominal/pelvic CT on 11/29/24 for abdominal pain and vomiting, and a CTA chest on 12/3/24 to rule out pulmonary embolism due to new-onset atrial fibrillation. Combined, these delivered ∼80 g of iodine. The patient was asymptomatic prior to imaging but subsequently developed palpitations, tremor, weight loss, and heat intolerance.On presentation, he had atrial fibrillation with rapid ventricular response. Urinary iodine levels were significantly elevated, with a spot urine iodine of 1512 µg/L on 12/12/24 and 684 µg/L on 12/18/24, reflecting recent high iodine exposure from contrast-enhanced imaging. A follow-up 24-hour urinary iodine test on 12/20/24 showed a level of 972 µg, further confirming ongoing iodine excess. Laboratory tests showed TSH <0.01 µIU/mL, free T4 4.7 ng/dL, and free T3 7.4 ng/dL. Thyroid antibodies were negative. A 2.2 cm left-lobe thyroid nodule was found on ultrasound. Due to recent iodine exposure, radioactive iodine uptake was not performed, as iodine saturation would have rendered the test uninterpretable. RAIU typically becomes reliable four to six weeks post-exposure.A presumptive diagnosis of Jod-Basedow hyperthyroidism was made. Methimazole 40 mg/day and beta-blockade were started, leading to partial improvement. He was readmitted with recurrent atrial fibrillation after missing a beta-blocker dose. Follow-up thyroid function tests showed a shift to hypothyroidism (TSH 10.53 µIU/mL, free T4 0.38 ng/dL), necessitating methimazole discontinuation. Further evaluation of the thyroid nodule via fine-needle aspiration and assessment of abdominal lesions were deferred until stable euthyroidism. Clinical Lessons This case illustrates how high-dose iodinated contrast can unmask thyroid autonomy, causing severe hyperthyroidism. The patient’s course, marked by new-onset atrial fibrillation, readmission, and hypothyroidism, highlights the importance of thorough risk assessment and post-contrast thyroid function monitoring. Baseline thyroid testing and ultrasound should be considered in high-risk individuals. Monitoring with thyroid function tests at two and four weeks post-exposure is crucial for detecting iodine-induced dysfunction. Careful antithyroid medication titration is necessary to avoid overtreatment and iatrogenic hypothyroidism. Recognizing Jod-Basedow hyperthyroidism in high-risk patients is vital to prevent arrhythmias and optimize thyroid management.Presentation: Monday, July 14, 2025

Disclosure: Z. Najeeb: None. M. Kaur: None. P. Ginier: None.Adrenal incidentalomas require thorough evaluation to assess the risk of malignancy and hormonal hypersecretion. The Endocrine Society guidelines recommend adrenal biopsy when: (1) the lesion is hormonally inactive, (2) imaging is not clearly benign, and (3) biopsy findings are expected to alter management. While malignancy and functional adenomas are common, infectious causes are rare but possible. Coccidioides species, endemic to the Southwestern United States, cause disseminated disease in about 1% of cases, which can involve the adrenal glands and mimic malignancy.A 75-year-old male with atrial fibrillation, hyperlipidemia, and chronic kidney disease stage 3B was referred for evaluation of a left adrenal incidentaloma. His history was notable for residence in an endemic region (Central Valley, CA), 40-lb unintentional weight loss, chronic night sweats, and extensive travel to Costa Rica, Turks and Caicos, Mexico, Fiji, Honduras, Mediterranean countries, and Alaska. Imaging revealed a 4.0 x 2.5 cm adrenal lesion with 39 Hounsfield units (HU). PET/CT demonstrated hypermetabolic bilateral adrenal thickening and a left adrenal nodule (SUVmax 11.4). Hormonal testing revealed normal-range catecholamines, aldosterone, renin, and a negative Cushing’s screen. An 8 AM cortisol of 11.4 µg/dL (ref 5-25) and ACTH of 24 pg/mL (ref 6-50) suggested a low likelihood of adrenal insufficiency.A CT-guided biopsy revealed necrotic tissue with histiocytes containing intracytoplasmic fungal spherules. Serology for Coccidioides was repeatedly negative (IgM/IgG, complement fixation, and immunodiffusion). Histoplasma serology was partially reactive, with a positive yeast-phase antibody titer of 1:32 (ref <1:8) and a positive M band, but negative mycelial-phase antibody and negative urine antigen. Serology for Blastomyces and Cryptococcus included negative urine and serum antigen tests, respectively. While histoplasmosis was considered, the patient’s geographic exposure and histopathologic findings were more consistent with Coccidioides, which can exhibit false-negative serology. An infectious disease specialist was consulted and initiated fluconazole 400 mg daily. After 10 months of therapy, a follow-up MRI showed a reduction in the adrenal mass to 2.8 cm, indicating treatment response.This case highlights the importance of considering rare fungal infections in the evaluation of adrenal masses, particularly in endemic regions. Multidisciplinary collaboration was essential in avoiding unnecessary adrenalectomy. While the patient does not currently require glucocorticoid replacement, ongoing monitoring is necessary given the potential for long-term adrenal insufficiency due to progressive glandular destruction.Presentation: Saturday, July 12, 2025

Abstract Disclosure: M.P. Reyes: None. V. Babu: None. S. Mishra: None. A. Mehta: None. Introduction:Radioactive iodine (RAI) is crucial for managing metastatic papillary thyroid carcinoma (PTC). However, chronic amiodarone therapy, with its high iodine content, can cause iodine overload, limiting RAI’s effectiveness. We present a case of metastatic PTC complicated by excess iodine from prolonged amiodarone use.Clinical Case:A 72-year-old woman with PTC, treated by total thyroidectomy in 2005 (no remnant ablation due to low risk), presented in 2024 with bilateral pulmonary nodules noted on routine imaging. Biopsy confirmed metastatic PTC (thyroglobulin, TTF1, and PAX8 positive). She had chronic atrial fibrillation managed with amiodarone for over a decade, resulting in significant iodine overload. Post-thyroidectomy hypothyroidism was treated with levothyroxine (175 mcg/day), maintaining TSH &amp;lt;0.1 mIU/L due to metastatic disease.Diagnostic RAI imaging was contraindicated by iodine saturation. Management included:1. Discontinuing amiodarone and initiating dofetilide to facilitate iodine clearance.2. Suppressive levothyroxine dosing was maintained to keep TSH levels below 0.1 mIU/L, minimizing stimulation of residual thyroid cancer cells.3. Monitoring urinary iodine and thyroid function during a washout period, with imaging to assess disease stability.4. Considering tyrosine kinase inhibitors if disease progressed while awaiting RAI eligibility.Currently, she remains clinically stable without significant progression, and future RAI eligibility is under reassessment.Clinical Lessons:This case highlights the unique complexities of managing metastatic PTC in the context of iodine excess from chronic amiodarone use. Key clinical lessons include:• Chronic amiodarone-induced iodine overload demands strategic tapering of amiodarone and the use of alternative antiarrhythmics.• Maintaining TSH suppression is critical to limiting tumor growth in metastatic PTC.• Close collaboration among endocrinology, cardiology, and oncology balances arrhythmia control and cancer management.• Tyrosine kinase inhibitors offer a viable bridge therapy when RAI is contraindicated or delayed. • Comorbidities, including the need for glycemic control and cardiovascular stability, underscore the importance of comprehensive, personalized care. Presentation: Monday, July 14, 2025

ABSTRACT Background: Accessible, low-cost digital programmes are emerging as a means by which to address high rates of mental health problems. However, the development and assessment of scalable training programmes for effective use of digital interventions has lagged. This is particularly important, as coach-supported digital interventions provide benefits that substantially and consistently exceed those of programmes that are entirely self-guided. Objectives: This report describes the evaluation of a brief coach training programme consisting of a two-hour workshop and six 1-hour consultation sessions for delivery of webSTAIR, a 10-module transdiagnostic web-based programme for trauma-exposed populations. Method: The training was provided to 68 mental health counsellors at Veteran Health Administration Readjustment Counselling Services, who delivered the treatment to 99 veteran clients. Results: A total of 51% of the coaches completed the programme. Client outcomes were encouraging. Veterans enrolled in the programme demonstrated significant and clinically meaningful improvements in functioning (Cohen’s d = 0.88), emotion regulation (Cohen’s d = 0.97), posttraumatic stress disorder (PCL-5 Cohen’s d = 0.61; ITQ Cohen’s d = 0.60), and depression (Cohen’s d = 0.53). Conclusions: The study contributes much needed information regarding evidence for the effectiveness of ‘light-touch’ training strategies. The data support the integration and testing of brief training programmes in the implementation and dissemination of evidence-based digital interventions. Strategies for improving training completion rates among busy providers and resource-burdened clinical services need to be considered.

Wildlife professionals routinely use potent sedatives and anesthetics when chemically immobilizing wildlife and zoo species in remote environments. Accidental exposure to these prescription veterinary drugs is rare but could be rapidly fatal. Commonly used agents include opioids and α2 adrenoreceptor agonists. These drugs can be reversed with specific antagonists; however, they are often not approved for human use. The protocol created here can be used by wildlife health professionals in a field setting with basic human emergency medical response training in coordination with local Emergency Medical Services (EMS). Key components include, building local relationships between EMS and wildlife professionals, focused EMS training, administering opioid and α2 adrenergic antagonists off label, and local evacuation procedures. This framework could allow wildlife management agencies or zoos to mitigate the risk of human exposures to these commonly used drugs, significantly improving occupational safety in an otherwise high-risk environment.

A 59-year-old man was struck by an automobile resulting in left anterior column posterior hemitransverse acetabular fracture with ureteral entrapment. Open reduction internal fixation was performed with removal of the ureter from the fracture. At follow-up 7 months post-op, the patient did not report significant hip or urinary symptoms, and implant position and fracture alignment remained intact. Surgeons should be mindful of possible ureteral injury associated with acetabular fractures. Awareness of this rare entrapment within medially displaced acetabular fractures may heighten clinical suspicion and improve management.