Sarcoidosis is a chronic inflammatory disease of unknown cause that can affect the heart and blood vessels, causing cardiomyopathy, pulmonary hypertension, and vasculitis. The pathological hallmark of sarcoidosis is the formation of noncaseating granulomas consisting of monocytes and dendritic cells, macrophages, multinucleated giant cells, and T cells. Sarcoidosis has features of autoimmune disease, and many candidate self-epitopes have been identified, but experimental validation is lacking. There is a strong hereditary component associated with the human leukocyte antigen region on chromosome 6. Symptoms of the disease may be subtle and often go unrecognized by patients and practitioners. Catastrophic events, including sudden cardiac death caused by lethal arrhythmias, can be the initial manifestation of the disease. Diagnosis is challenging and limited by the lack of sensitive and specific diagnostic tools, which also hampers monitoring of disease activity. Here, we discuss the cardiovascular manifestations and underlying immunobiology of sarcoidosis. We also review current diagnostic and treatment approaches for cardiac sarcoidosis, as well as the challenges faced by patients and clinicians and opportunities for future research.

INTRODUCTION:Sleep apnea (SA) is an important comorbidity in end-stage renal disease (ESRD) patients. The association between SA and cardiac and neurological disease is known. This study investigates the relationship between SA and cardiovascular and cerebrovascular outcomes in the ESRD population. METHODS:In a retrospective cohort study, the United States Renal Data System was queried to identify ESRD patients aged 18-100 years in whom hemodialysis had been initiated between 2005 and 2013. Diagnoses of SA and clinical comorbidities were determined from International Classification of Disease-9 codes. Demographic variables were obtained from Centers for Medicare and Medicaid Services Form-2728. Logistic regression was used to examine the association of SA with myocardial infarction (MI) or with stroke, controlling for demographic and clinical variables. RESULTS:Of 858,131 subjects meeting the inclusion criteria, 587 had central SA, and 22,724 had obstructive SA. The SA cohort was younger, more likely to be male and Caucasian compared to the non-SA cohort. Patients with SA also had more tobacco and alcohol use, hypertension, heart failure, and diabetes. Central SA (aRR = 1.69, 95% CI = 1.28-2.23) and obstructive SA (aRR = 1.15, 95% CI = 1.09-1.21) were associated with an increased risk of stroke but not MI. CONCLUSION:In the ESRD population, a diagnosis of central SA or obstructive SA increased the risk of stroke, but not MI. Early identification and treatment of SA in the ESRD population may help reduce the risk of stroke in these patients.

In the general population, abdominal aortic aneurysm (AAA) is synonymous with vascular disease and associated with increased mortality. Vascular disease is common in end-stage renal disease (ESRD) patients on dialysis, but there is limited information on AAA in this population. To address this issue, we queried the United States Renal Data System for risk factors associated with a diagnosis of AAA as well as the impact of AAA on ESRD patient survival. Incident dialysis patients from 2005 to 2014 with AAA and other clinical comorbidities were identified using ICD-9 and ICD-10 codes. Time to death was defined using the time from the start of dialysis to the date of death or to December 31, 2015. Cox proportional hazards (CPH) modeling was used to determine the adjusted hazard ratio (aHR) and 95% confidence intervals (CI) for death. From a total cohort of 820,826, we identified 21,631 subjects with a diagnosis of AAA. When compared to patients without AAA, AAA patients were older and more likely to be of white race and male gender, have a higher mean Charlson comorbidity index (CCI), have hypertension as the ESRD etiology, and use tobacco. Although a bivariate CPH model showed that AAA patients had an increased mortality risk compared to patients without the diagnosis, in the final CPH model, AAA patients had a decreased risk of mortality (aHR = 0.83, 95% CI 0.81–0.84) due to confounding with age. These results suggest that AAA is not associated with increased risk of death in ESRD patients after controlling for various demographic and clinical risk factors.

Background Insomnia, a known cardiovascular risk factor, is common in end-stage renal disease (ESRD) patients. There is growing acknowledgment of a potential bidirectional relationship between cardiovascular diseases and sleep disorders. We previously assessed the risk factors for common sleep disorders in ESRD patients. This follow-up study assesses the demographic and clinical cardiovascular-related risk factors for insomnia diagnosis in ESRD patients, given their increased cardiovascular burden. Methods This study is a retrospective analysis of the United States Renal Data System to evaluate risk factors for insomnia diagnosis. All patients in the USRDS who started dialysis between 2005 and 2019 were eligible for inclusion. Demographic risk factors analyzed were age, race, sex, ethnicity, dialysis modality, and access type. Cardiovascular risk factors, including obstructive sleep apnea (OSA) and central sleep apnea (CSA), were also evaluated. Results Female sex, OSA, CSA, myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease, obesity, and hypertension were associated with an increased risk of insomnia. Increasing age, non-white race, Hispanic ethnicity, and catheter or other/peritoneal dialysis access type were associated with a decreased risk of an insomnia diagnosis. Conclusion Various cardiovascular diseases were independent risk factors for an insomnia diagnosis in this retrospective cohort. Further study is indicated to investigate potential mechanisms underlying this connection.

Vitiligo is an autoimmune condition that causes patchy skin depigmentation. Although the mechanism by which vitiligo induces immunocompromise is unclear, other related autoimmune diseases are known to predispose those affected to infection. Individuals with vitiligo exhibit epidermal barrier disruption, which could potentially increase their susceptibility to systemic infections; patients with renal disease also show a predisposition to infection. Nevertheless, there is little research addressing the risk of infection in dialysis patients with vitiligo in comparison to those without it. A retrospective analysis was performed on patients with end-stage renal disease (ESRD) in the United States Renal Data System who started dialysis between 2004 and 2019 to determine if ESRD patients with vitiligo are at an increased risk of bacteremia, cellulitis, conjunctivitis, herpes zoster, or septicemia. Multivariable logistic regression modeling indicated that female sex, black compared to white race, Hispanic ethnicity, hepatitis C infection, and tobacco use were associated with an enhanced risk of vitiligo, whereas increasing age and catheter, versus arteriovenous fistula, and access type were associated with a decreased risk. After controlling for demographics and clinical covariates, vitiligo was found to be significantly associated with an increased risk of bacteremia, cellulitis, and herpes zoster but not with conjunctivitis and septicemia.

Obstructive sleep apnea (OSA) is a prevalent pathology with current modalities of treatment including continuous positive airway pressure (CPAP), surgery, weight loss, hypoglossal nerve stimulation, and pharmacotherapy. While CPAP is the current standard treatment for OSA, lack of tolerance and side effects necessitate alternative modalities of treatment. Various pharmacologic agents exist with mechanisms that may target OSA. Early trials have demonstrated efficacy of noradrenergic-antimuscarinic combinations to stimulate the airway, promote pharyngeal muscle tone, and prevent airway collapse. These agents, which we discuss in detail, have demonstrated significant reductions in apnea-hypopnea index (AHI) and lowest oxygen saturations based on preliminary studies. Glucagon-like peptide 1 receptor agonists (GLP-1RA), which stimulate endogenous insulin, reducing glucagon release, and decreasing gastric emptying, have shown positive results for OSA patients through weight loss with reductions in AHI. In this narrative review article, we highlight the mechanisms, current data, and future potential for multiple drug classes, including respiratory stimulants and GLP-1RAs.

Chronic rhinosinusitis (CRS) is known to occur in most cystic fibrosis (CF) patients. This phenomenon occurs because the genetic mutations in CF cause impaired chloride ion transport, which affects water transport and thus leads to thick mucus that cannot be cleared easily in both the lower and upper airways. While improvements continue to be made in treatment modalities for CF patients in terms of modulator therapies, the effect on sinus disease symptoms and the role of the otolaryngologist (ENT) continues to evolve. This study investigates the sinus symptoms of CF patients with comparison to ENT involvement in their care, the histories of polyps and sinus surgeries of these CF patients, and how their initiation to modulator treatment has affected ENT involvement in their care. A retrospective health records review was conducted including patients from Augusta University Adult Cystic Fibrosis Center with stratification based on demographics, mutations, modulators, ENT clinic visits, history of polyps or nasal surgery, and reported symptoms of headaches, olfactory dysfunction, and sleep problems. 98 patients of the Augusta University Adult Cystic Fibrosis Center met the inclusion criteria of this study. Most of the patients with reported ENT visits in the past 10 years were white and between the ages of 20-29. The most common modulator therapy of the CF patients was elexacaftor-tezacaftor-ivacaftor at 72.22%. More than half of the patients had a history of sinonasal surgery, and almost half had a history of polyps. In comparing ENT visits to the initiation of modulator therapy, 24% of the patients with reported ENT visits saw an ENT after starting modulator therapy. CRS can contribute to morbidity in CF patients with most patients requiring surgical intervention in their lifetime. Additionally, persistent sinonasal symptoms can reduce the quality of life in CF patients. Despite treatment with modulator therapies, otolaryngologists continue to have a role in interdisciplinary CF management.CF- Cystic Fibrosis; CFTR- Cystic Fibrosis Transmembrane Regulator; CRS- Chronic Rhinosinusitis; EMR- Electronic Medical Record; ENT- Otolaryngologist

Background Sleep disturbances in patients with end-stage renal disease (ESRD) are common and more prevalent than in the general population. This study aims to assess the demographic and clinical risk factors for the diagnosis of sleep disorders in ESRD patients. Methods This study is a retrospective analysis of the United States Renal Data System (USRDS) to evaluate risk factors for the diagnosis of sleep disorders, including hypersomnolence, insomnia, restless leg syndrome (RLS), or obstructive or central sleep apnea (OSA/CSA). All ESRD subjects enrolled in the USRDS between 2004-2015 were eligible for inclusion. The risk factors analyzed were age, race, sex, ethnicity, access type, dialysis modality, and the Charlson Comorbidity Index (CCI). All statistical analysis was performed using SAS 9.4, and statistical significance was assessed using an alpha level of 0.05. Descriptive statistics on all variables overall and by each sleep diagnosis were determined. Results Increasing age, black race, other race, and Hispanic ethnicity were associated with decreased risk of each sleep diagnosis while CCI was associated with increased risk. Females were at increased risk of RLS and insomnia while males were at increased risk of OSA/CSA. Catheter and graft access decreased risk of RLS but increased risk of insomnia compared to AVF access. Catheter access increased risk of OSA/CSA compared to graft access. Hemodialysis increased risk of OSA/CSA compared to peritoneal dialysis. Conclusions Some ESRD patients are at an increased risk for diagnosis of sleep disorders based on age, race, sex, comorbid health conditions, and dialysis modality.

Background and Objectives: Atopic dermatitis (AD), also known as eczema, is a common chronic inflammatory skin condition affecting 16.5 million adults in the United States. AD is characterized by an impaired epidermal barrier that can predispose individuals to infection. End-stage renal disease (ESRD) is also commonly complicated by infections due to chronic vascular access and immune-system dysfunction, possibly related to uremia. Multiple studies have reported that renal disease is a common comorbidity in adults with atopic dermatitis. The aim of this study was to determine whether AD is a risk factor for certain infections in patients with ESRD. Materials and Methods: Using the United States Renal Data System, a retrospective cohort analysis was conducted on adult ESRD patients initiating dialysis between 2004 and 2019 to investigate associations between infections and AD in this population. Results: Of 1,526,266 patients, 2290 were identified with AD (0.2%). Infectious outcomes of interest were bacteremia, septicemia, cellulitis, herpes zoster, and conjunctivitis. In all infectious outcomes except for conjunctivitis, patients with the infectious outcomes were more likely to carry a diagnosis of AD. After controlling for demographic and clinical covariates, AD was associated with an increased risk of cellulitis (adjusted relative risk (aRR) = 1.39, 95% confidence interval (CI) = 1.31-1.47) and herpes zoster (aRR = 1.67, CI = 1.44-1.94), but not with bacteremia (aRR = 0.96, CI = 0.89-1.05), septicemia (aRR = 1.02, CI = 0.98-1.08), or conjunctivitis (aRR = 0.97, CI = 0.740-1.34). Conclusions: Overall, after controlling for demographic and clinical covariates and adjusting for person-years-at-risk, AD was associated with an increased risk for some, but not all, infections within the population of patients with ESRD.

SESSION TITLE: Lung Cancer Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Pulmonary pleomorphic carcinoma (PC) is a rare, aggressive subtype of sarcomatoid carcinoma. It usually presents as a peripheral mass comprised of a mixture of giant and spindle cells. The incidence of PC is between 0.1-0.4% of all lung cancers and tends to metastasize to adjacent structures in the early stage [1]. Here we discuss a case of metastatic PC masquerading as abdominal pain from small bowel obstruction. CASE PRESENTATION: An 87-year-old male with a history of adenocarcinoma, COPD, hypertension, hyperlipidemia, diabetes, smoking and chronic kidney disease presented with abdominal pain for 3 days. He reported symptoms of loose stool, diarrhea, and excessive flatulence in the week prior. CT scan of the abdomen and pelvis revealed small bowel obstruction from a right lower quadrant abdominal mass measuring 7x8 cm (Figure 1). After undergoing an exploratory laparotomy with resection, patient was found to have an undifferentiated malignant tumor with sheets of spindle cells, giant cells, and some small cells with a rhabdoid/signet ring cell appearance. Numerous mitotic figures with areas of tumor necrosis were also noted. The tumor was centered in the mesentery and extended to the muscularis propria. Immunohistochemical staining was positive for keratin AE1/AE3, CK7, TTF-1, and Napsin A. Additional CT imaging of the abdomen/pelvis revealed a 10 cm mass in the gastrohepatic region with an enlarging adrenal mass and a lytic lesion in the sacrum (Figure 2). Overall, the morphology, immunostaining, and patient history supported a diagnosis of a metastatic PC from the lung. DISCUSSION: Tumors of the small intestine are usually metastatic and originate from adjacent organs, such as stomach, pancreas, and colon [2]. Metastatic primary lung cancer to the gastrointestinal tract is rare, occurring in 0.2-1.7% of cases [1]. Initial findings are subtle and isolated, such as a single polyp or an obstruction [2], but abdominal pain is the most common presenting symptom, followed by intestinal perforation, melena, nausea, and vomiting [3]. These symptoms can be attributed to mesenteric masses that infiltrate into the bowel wall [3].There have only been 44 unique case reports of primary lung metastasizing to the colon, of which 45% can be attributed to squamous cell carcinoma, 11% to small cell carcinoma, and 7% to large cell carcinoma [2], Only 2 cases of metastatic PC to the colon, and small bowel were reported [2]. Small bowel obstructions are normally most prevalent in patients with ovarian cancer (5.5-42%), colorectal cancer (4.4-24%), and gastric cancer [2]. As such, our case of metastatic PC causing small bowel obstruction is truly a unique pathology. CONCLUSIONS: Pulmonary PC is an aggressive tumor that rarely metastasizes to the gastrointestinal tract. Because of its atypical cell morphology and poor differentiation, it presents as a diagnostic challenge for clinicians. Despite its rarity, clinicians should consider the possibility of gastrointestinal metastasis when evaluating lung cancer patients exhibiting signs of abdominal pain. REFERENCE #1: Zhang X, Wang Y, Zhao L, Jing H, Sang S, Du J: Pulmonary pleomorphic carcinoma: A case report and review of the literature. Medicine (Baltimore). 2017, 96:e7465. 10.1097/md.0000000000007465 REFERENCE #2: Parker NA, McBride C, Forge J, Lalich D: Bowel obstruction caused by colonic metastasis of lung adenocarcinoma: a case report and literature review. World J Surg Oncol. 2019, 17:63. 10.1186/s12957-019-1611-y REFERENCE #3: Burnette RE, Ballard BR: Metastatic pleomorphic carcinoma of lung presenting as abdominal pain. J Natl Med Assoc. 2004, 96:1657-1660 DISCLOSURES: No relevant relationships by Arjun Bhatt No disclosure on file for Jayanth Keshavamurthy No relevant relationships by Paul Kirkpatrick No relevant relationships by Sameena Salcin No disclosure on file for Varsha Taskar

Sleep apnea (SA) is highly prevalent in the end-stage renal disease (ESRD) population. However, the impact of SA on mortality in ESRD is unclear. This study investigates the relationship between SA and mortality in ESRD. The United States Renal Data System was queried in a retrospective cohort study to identify ESRD patients aged 18–100 years who initiated hemodialysis between 2005 and 2013. Diagnoses of SA and comorbidities were determined from International Classification of Disease-9 codes and demographic variables from Centers for Medicare and Medicaid Services Form-2728. Cox proportional hazards models were used to examine the association of SA with mortality controlling for multiple variables. Of 858,131 subjects meeting inclusion criteria, 587 were found to have central SA (CSA) and 22,724 obstructive SA (OSA). The SA cohort was younger and more likely to be male and Caucasian compared to the non-SA cohort, with more diagnoses of tobacco and alcohol use, hypertension, heart failure, and diabetes. Both CSA (adjusted hazard ratio (aHR) = 1.42, 95% confidence interval (CI): 1.29–1.56) and OSA (aHR = 1.35, 95% CI: 1.32–1.37) were associated with increased mortality. Other variables associated with increased mortality included age, dialysis initiation with a catheter or graft, alcohol use, hypertension, and cardiovascular disease. Factors associated with decreased mortality included female sex, black race, Hispanic ethnicity, diagnosis of heart failure or diabetes, and an ESRD etiology of glomerulonephritis or polycystic kidney disease. Since a diagnosis of either OSA or CSA increases mortality risk, early identification of SA and therapy in this ESRD population may improve survival.