bluuebunny/crossref_metadata_2025 huggingface dataset:
SUN-677 The Warburg Effect: A Case of Persistent Hypoglycemia and Lactic Acidosis
Authors: Majety Priyanka , Erenler Feyza , Castillo Ma Dolores Del , Siegel Richard D
Published: May 2020

Background: It is well established that malignant cells are able to metabolize glucose to lactate in the presence of oxygen, known as the Warburg effect (WE) - a rare metabolic complication of malignancies, presenting with lactic acidosis & hypoglycemia. It signifies a poor prognosis with high mortality rates. We present the case of a woman with malignancy who presented with persistent hypoglycemia requiring a dextrose drip and type B lactic acidosis. Clinical case: A 63-year-old female was referred to our institution for persistent hypoglycemia and lactic acidosis after being admitted to another hospital for a urinary tract infection. Her history was notable for generalized fatigue & weight loss. She had lactic acidosis (18-25mEq/L; Normal: 0.5–2.2mEq/L) despite stable hemodynamics that did not improve with resuscitation & antibiotics. Her hospital course was complicated by worsening mental status & non- hypoxic respiratory distress due to profound acidosis, requiring intubation. She required a dextrose infusion of up to 40g/hour to maintain normoglycemia and with the infusion, an increase in lactate level was noted. Workup to rule out insulin-dependent hypoglycemia, adrenal insufficiency, GH deficiency, MELAS, mesenteric ischemia & drug-related lactic acidosis was unremarkable. EEG was not suggestive of seizure activity. Initial labs were notable for elevated levels of CA-19-9 408U/mL (normal: 0–34), & CA 125 430U/mL (normal: 0–34) which were attributed to her newly diagnosed cirrhosis. However, the degree of her liver dysfunction was felt to be not severe enough to cause hypoglycemia. Imaging studies looking for tumors were unrevealing. A bone marrow biopsy done to rule out occult malignancy showed metastatic carcinoma with neuroendocrine features. Further treatment was not pursued by her family. Based on the diagnosis of metastatic cancer, it was felt that her persistent hypoglycemia was due to the Warburg effect. Conclusion: The Warburg effect (WE) is observed in cancers when the malignant cells utilize glycolysis over oxidative phosphorylation, regardless of oxygen content, for energy production. This involves aerobic glycolysis & lactic acid is its by-product. Cancer cells use more glucose via the glycolysis pathway to meet their demands leading to hypoglycemia & concurrent lactic acidosis despite normal oxygen levels. WE is a rare but severe complication of malignancies that signifies a poor prognosis. Patients with this complication need to be monitored closely until definitive treatment can be implemented. This case highlights the importance of maintaining a high clinical index of suspicion for diagnosing WE. Reference Elhomsy G. C., Eranki V., Albert S. G., et al. “Hyper-warburgism,” a cause of asymptomatic hypoglycemia with lactic acidosis in a patient with non-Hodgkin’s lymphoma. The Journal of Clinical Endocrinology & Metabolism. 2012;97(12):4311–4316.
SUN-392 Bone Mineral Density and Body Mass Index in Men with Cystic Fibrosis
Authors: Jawahar Abhinaya , Krishnasamy Sathya S , Ramirez Allan , O’Hagan Adrian , Winters Stephen J
Published: May 2020

Osteoporosis is an important endocrine complication of cystic fibrosis (CF). Low bone mass in CF patients has multiple contributing causes including vitamin D deficiency, calcium malabsorption, pulmonary infection and cytokine production, malnutrition, a sedentary life style, cumulative steroid dose, delayed puberty, and hypogonadism. The objective of this study was to examine the relationship between BMI and bone density of the hip and spine in adult men with CF. We conducted a retrospective chart review of adult men with CF receiving care at an academic medical center. Medical records of 43 men ages 19-60 (32.1±9.8) years were reviewed. 8 men with lung transplant, or receiving chronic glucocorticoid or androgen treatment were excluded. One subject was excluded as his BMI was >3SD above the mean. BMD was measured by dual-energy x-ray absorptiometry at the lumbar spine (LS) and hip. The mean ± SD BMI of the study population was 24.10 ± 5.24 kg/m2, mean LS BMD was 0.96 ± 0.204 g/cm2 and mean hip BMD was 0.701 ± 0.382 g/cm2. Men were divided into three groups: normal BMD, osteopenia, or osteoporosis, based on current guidelines. 8 (24%) men were found to have normal bone density (Z=0.40±0.60), 19 (56%) had osteopenia (Z= -1.57±0.67) and 7 (20%) had osteoporosis (Z= -3.27±0.83). Of these 7, 6 had osteoporosis of the LS only, and one patient had osteoporosis of the hip; 5 were being treated with a bisphosphonate. The three groups of men were similar in age (P=0.93). 25OH-vitamin D levels were 22.6±4.4, 35.6±12.7 and 27.0±13.4 ng/mL, respectively (p=0.03). There was a significant (p=0.023) difference in BMI among these three groups (26.33±4.80 vs 23.25 ± 3.01 vs 20.96±3.64 kg/m2). BMI was strongly positively correlated with LS BMD (r = 0.54, P<0.001) but not with BMD of the hip (r = 0.11, p=0.55). Moreover, LS BMD was highly predicted by body weight (r = 0.90, P<0.0001) but not significantly by height (r = 0.26, p=0.16). These findings indicate that CF-related bone disease (CF-RBD) affecting the LS is common in adult men, and that body weight is a major determinant of LS BMD in men with CF. Possible mechanisms for this association include signaling pathways related to nutritional status and sex steroids.
OR16-04 OTX2 Mutations in Congenital Hypopituitarism Patients
Authors: Gregory Louise Cheryl , Gergics Peter , Patti Giuseppa , McCabe Mark J , Maghnie Mohamad , Spadoni Emanuela , Camper Sally A , Dattani Mehul T
Published: May 2020

The transcription factor OTX2 is implicated in pituitary, ocular and craniofacial development. Mutations have been described in patients with variable congenital hypopituitarism (CH) ranging from isolated growth hormone deficiency (IGHD) to combined pituitary hormone deficiency (CPHD) with/without an ectopic posterior pituitary (EPP).We aimed (i) to establish the contribution of OTX2 mutations in the etiology of CH in a sub-cohort of patients and to study their functional consequences and (ii) establish a detailed human OTX2 expression profile in a hypothalamo-pituitary (HP) context. We screened 127 patients from national (n=103) and international centers (n=24) on the septo-optic dysplasia (SOD) spectrum with variable eye abnormalities. Eye abnormalities included micro/anophthalmia, retinal dystrophy and/or coloboma in 29 of these patients, with the rest having optic nerve hypoplasia (ONH). An EPP was reported on MRI in 35 patients. The cohort previously tested negative for mutations in HESX1, SOX2, SOX3, PROKR2 and GH1. Transactivation assays involved a dual-luciferase reporter in murine hypothalamic GT1-7 neurons transiently transfected with OTX2 constructs. In situ hybridization was performed to analyze human brain OTX2 expression during embryogenesis. Seven heterozygous OTX2 changes were identified: two chromosomal deletions spanning OTX2 in patients with micro/anophthalmia, GHD and an EPP, with one patient having cerebellar hypoplasia. Three missense substitutions resulting in truncated proteins: (i) the previously reported p.S138* and (ii) p.C170*, in two patients with retinal dystrophy, EPP and IGHD respectively, and (iii) the novel p.E79* in a patient with micro/anophthalmia, EPP and CPHD. A novel insertion-deletion resulting in a truncated protein p.S167* in a patient with microphthalmia, GHD, ONH, EPP and an enlarged abnormal pituitary, and a novel deletion resulting in a frameshift p.Val139Aspfs*39 in a patient with microcephaly, microphthalmia, ONH and an EPP were also identified. The human OTX2 variants caused a significant reduction in transactivation compared to wild type. Our gene expression data identified human OTX2 transcripts in the posterior pituitary, retina, ear, thalamus, choroid plexus, and in the hypothalamus during embryogenesis, but not in RP. To conclude, we identified OTX2 variants in 7 unrelated CH patients with eye abnormalities including 3 with retinal dystrophy and one with a cerebellar abnormality. As OTX2 is involved at multiple levels during HP development, these patients should be monitored for evolving endocrinopathies. Human OTX2 is expressed in the posterior pituitary, the retina and the ear at CS19 and 20 (between 6-7 weeks gestation), and in areas of the hindbrain at CS23, but not in RP at any stage analyzed in this study. The endocrine phenotypes in patients with OTX2 mutations are most likely of hypothalamic origin.
MON-338 Severe Hypophosphatemia Induced by Intravenous Ferric Carboxymaltose Therapy for Iron Deficiency Anemia
Authors: Tam Matthew , Bhabhra Ruchi
Published: May 2020

Background: Ferric carboxymaltose (Injectafer), a newer intravenous iron agent permits larger iron concentrations to be delivered in fewer doses compared to traditional preparations of intravenous iron. However, ferric carboxymaltose has been shown to up-regulate fibroblast growth factor 23 (FGF23) which can result in severe hypophosphatemia. We present a case illustrating this phenomenon.

Clinical Case: A 48 year-old Caucasian female was admitted to the emergency department with complaints of gradual onset muscle weakness and severe exhaustion. Over the course of several months she noticed significant muscle weakness in all extremities.

Her co-morbidities included morbid obesity (status-post Roux-en-y bypass surgery), asthma, and hereditary angioedema. Due to her history of gastric bypass surgery, the patient required monthly iron sucrose infusions over the previous two years. Her regimen was changed to ferric carboxymaltose (Injectafer) about five months prior to the admission, receiving 750mg treatments twice monthly.

On admission, she was found to have severe hypophosphatemia of 1.5 mg/dL (2.1 – 4.7 mg/dL) with 25-OH vitamin D 21 ng/mL and PTH of 155 pg/mL. A random urinary phosphate was 72 mg/dL with a urine creatinine of 45 mg/dL, with calculated fractional excretion of phosphorus of 74%. Further diagnostic tests including EMG / nerve conduction studies, inflammatory markers, autoimmune workup, and creatine kinase were negative. She was found to have a ferritin of 2159 ng/mL (11 – 306 ng/mL) from previous baseline of 12.8 ng/mL with normal ESR and CRP. This was elucidated to be due to iron overload from IV iron infusions out of proportion to her needs. Therefore, ferrric carboxymaltose was discontinued. Her symptoms gradually improved with phosphorus and vitamin D supplementation. Two months later, when seen by Endocrinology, her ferritin was 1220 ng/mL, PTH 44 pg/mL, and phosphorus normalized to 2.6 mg/dL.

Conclusion: Ferric carboxymaltose can cause profound phosphaturia and hypophosphatemia by inhibiting the cleavage of intact FGF23 to the inactive form, a mechanism similar to autosomal dominant hypophosphatemic rickets. Previous clinical trials show the incidence of hypophosphatemia to be as high as 41-70%. We conclude that baseline phosphorus and vitamin D levels should be obtained prior to therapy and monitored closely during treatment.

Reference: Adkinson NF et al. Comparative safety of intravenous ferumoxytol versus ferric carboxymaltose in iron deficiency anemia: A randomized trial. Am J Hematol. 2018;93(5):683.
SAT-713 Novel Estrogenic Gene Regulation Induced by OTC Medications Containing Paraben Preservatives Is Dependent on Concentration that Varies Between Products and Batches
Authors: Baer Caroline , Ragland Emily , Ma Peng , Zhang Changde , Skripnikova Elena , Wiese Thomas E
Published: May 2020

Methylparaben, ethylparaben, and propylparaben are widely used as preservatives in food products, cosmetics, and pharmaceuticals. Parabens have been shown to be weak estrogens and this laboratory has described that extracts of some over the counter (OTC) medications with paraben preservatives can induce estrogen activity in tissue culture-based bioassays. At the same time, this laboratory determined that extracts from OTC medications containing the laxative bisacodyl induce estrogen activity regardless of parabens present and that bisacodyl is estrogenic. The current report describes the use of paraben standards and LC-MS analysis to determine paraben concentrations in extracts from OTC medications (Calcium Carbonate, Bisacodyl, Ibuprofen, Diphenhydramine, and Benzoyl Peroxide) used in previous studies. Also described is the application of the Qiagen RT2 Profiler PCR Array for Human Estrogen Receptor Signalling to determine gene induction profiles in MCF-7 cells treated with methyl, ethyl or proplyparaben, or each of the five pairs of OTC medication extracts (with or without parabens) relative to estradiol treatment. LC-MS analysis of extracts confirmed that five of six OTC medications labeled as paraben-free contain no detectable parabens, while one “paraben free” extract included measurable levels of parabens. At the same time, all of the extracts of OTC medications with paraben ingredients, some of which induce estrogen activity, were found to contain a wide range of paraben concentrations. A threshold range of paraben concentration in OTC medications is required to induce estrogen activity in bioassays. Analysis of paraben concentrations of extracts from different product lots of the same OTC medication identified discrepancies in the amount of paraben between batches. PCR Array profiles of the three paraben standards and the OTC medication extracts share some gene induction characteristics induced by estradiol. At the same time, methyl, ethyl and propylparabens induced unique gene array profiles that are shared by the OTC medication extracts containing parabens. The extracts of OTC medications containing bisacodyl stimulated a distinct gene induction profile that has some features of the profiles of estradiol and paraben treatment. This study highlights both the capacity for paraben preservatives in OTC medications to induce novel estrogen activity (gene induction) and the importance of determining the paraben concentration in OTC medications to determine estrogen potential. While the capacity for OTC medications containing parabens or other estrogenic substances to induce estrogen activity in individuals using the medications is unclear, consumers may want to know the potential for estrogen activity in these products.
SAT-418 Finding the Needles in the Haystack: Harnessing the Electronic Health Record to Find Thyroid Immune Related Adverse Events
Authors: Quandt Zoe , Trupin Laura , Evans Michael , Schmajuk Gabriela , Anderson Mark Stuart , Bluestone Jeff A , Jinoos Yazdany
Published: May 2020

Background: Immune checkpoint inhibitors (CPIs) are being used to effectively treat a growing number of cancers but can cause immune related adverse events (irAE). Thyroid dysfunction is the most common endocrine irAE. A meta-analysis of clinical trials estimated that following CPI exposure, 6.6% will become hypothyroid and 2.9% will have hyperthyroidism1. It is unclear if this reflects the real-world incidence of these irAEs. We used electronic health record (EHR) data to identify patients who developed thyroid dysfunction after CPI to estimate the real-world incidence of these irAEs.

Methods: Data were derived from the EHR of a large U.S. academic center. We identified subjects treated with CPIs between 2012 and 2018 and excluded those with thyroid cancer or pre-existing thyroid disease. Thyroid dysfunction was identified as either a TSH > 10, an abnormal free T4 or a prescription for thyroid hormone replacement or anti-thyroid medication. Those with thyroid dysfunction were then categorized as having pre-existing disease or a new-onset thyroid irAE based on the timing of CPI initiation. Logistic regression was used to evaluate the association of thyroid irAE with age, gender, CPI and type of cancer.

Results: In total, 1146 individuals without pre-existing thyroid disease that received CPIs were assessed. Pembrolizumab was the most common treatment (45%), followed by nivolumab (20%). Less than 10% of subjects received atezolizumab, durvalumab, ipilimumab monotherapy, combined ipilimumab/nivolumab, or other combinations of CPIs. Melanoma was the most common cancer treated (32%), followed by non-small cell lung cancer (13%). The prevalence of any other cancer was < 10% each. Overall, 19% developed thyroid irAEs. After adjustment for gender and age, the type of cancer was significantly associated with new onset thyroid dysfunction (p=0.01). The rates of thyroid irAEs ranged from 10% in glioblastoma to 40% in renal cell cancer. Although there was no significant association between irAEs and specific CPIs in the overall analysis, thyroid irAEs were more common in subjects who received combined ipilimumab/ nivolumab (31%) compared to pembrolizumab (18%, p=0.03), nivolumab (18%, p<0.01) and ipilimumab (15%, p=0.02).

Conclusion: Thyroid irAEs are much more common in real world practice than in clinical trials and there is emerging evidence that certain cancer types incur a higher risk of thyroid irAEs even after adjustment for CPI exposure. Clinicians and patients should be educated about these risks. Future work should focus on exploring the reasons underlying the differing rates of thyroid irAEs among different cancers including effect on cancer outcomes.

1Barroso-Sousa et al. Incidence of Endocrine Dysfunction Following the Use of Different Immune Checkpoint Inhibitor Regimens. JAMA Oncol. 2017; 02215: 1–10.
SUN-269 Activation of GFRAL Neurons Decreases Food Intake via Aversive Pathways
Authors: Sabatini Paul , Frikke-Schmidt Henriette , Rupp Alan , Gordian Desiree , Myers Jr Martin , Seeley Randy John
Published: May 2020

Growth and differentiation factor 15 (GDF15), an anorexigenic peptide that represents a promising candidate for anti-obesity treatment, acts via GDNF Family Receptor Alpha Like (GFRAL), which is expressed almost exclusively on a subset of neurons in the area postrema (AP). To determine the function and mechanisms of action for GFRAL neurons, we generated Gfralcre and conditional GfralCreERT mice. Although their chemogenetic (DREADD-mediated) activation promoted FOS in a variety of brainstem, hypothalamic, and limbic nuclei, GFRAL neurons projected only to the nucleus of the solitary tract (NTS) and the parabrachial nucleus (PBN), where they innervated and activated aversive/anorexigenic GCRP-expressing cells. Tetanus-toxin-mediated silencing of PBN CGRP neurons abrogated the aversive and anorexic effects of GDF15. Furthermore, while non-gastrointestinal (GI) stimuli (e.g., GDF15 and LPS, but not feeding or gut peptide mimetics) activated GFRAL neurons, chemogenetically activating these cells decreased gastric emptying, suppressed feeding, and promoted a conditioned taste aversion. These findings suggest that GFRAL neurons link non-GI anorexigenic signals to the control of gut physiology and to the aversive suppression of food intake. Additionally, because the chemogenetic activation of GFRAL neurons suppressed food intake more strongly than GDF15 in lean mice, additional modes of activating GFRAL neurons may augment the anorectic potential of GDF15.
OR27-05 Sexual Desire Changes in Transgender Individuals upon Initiation of Hormone Treatment; Results from the Longitudinal ENIGI Study
Authors: Defreyne Justine , Elaut Els , Kreukels Baudewijntje , Fisher Alessandra Daphne , Castellini Giovanni , Staphorsius Annemieke , Heijer Martin Den , Heylens Gunter , T’Sjoen Guy G
Published: May 2020

Introduction: Several steps in the transitioning process may affect sexual desire in transgender people. This is often underexposed by those providing gender affirming care. Testosterone therapy in transgender men (TM) generally leads to increasing frequency of desire, masturbation, sexual fantasies and arousal. Studies in transgender women (TW) are inconclusive: some report an increase in the prevalence of hypoactive sexual desire after initiation of hormone therapy, whereas others have shown a positive impact of hormonal therapy on sexual quality of life. The current study prospectively assesses sexual desire during the first three years of hormonal therapy (HT) in transgender people. Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Sexual desire was prospectively assessed in 766 participants (401 TW, 364 TM) by Sexual Desire Inventory (SDI) during a three-year follow-up period, starting at the initiation of hormone treatment (HT). SDI scores were analyzed as total, dyadic and solitary SDI scores. At baseline, psychological questionnaires were administered. Sex steroids were measured at each follow-up visit. Data were analyzed cross-sectionally and prospectively. Results: In TW, total, dyadic and solitary SDI scores decreased during the first three months of HT. However, after 36 months, total and dyadic SDI scores were higher than baseline scores. Solitary scores after 36 months were comparable to baseline scores. In TM, total, dyadic and solitary SDI scores increased over the first three months, remaining stable thereafter. However, total and dyadic SDI scores after thirty-six months were comparable to baseline scores, whereas solitary scores remained higher than baseline. Factors associated with a prospective increase in SDI scores included having undergone gonadectomy, no longer experiencing vaginal bleedings (in TM) or higher gender dysphoria levels at baseline (in TM only). Factors associated with higher cross-sectional SDI scores included being in a relationship, undergoing gonadectomy, no longer experiencing vaginal bleedings (TM), lower gender dysphoria scores (TW only) and lower body dysphoria scores (TW only). Conclusion: Gender affirming hormonal therapy induces short-term changes in sexual desire in transgender people. Over a longer period of time, a net increase in dyadic sexual desire in TW receiving feminizing HT was observed. Sexual desire scores comparable to baseline in TM receiving virilizing HT were found. We observed no correlation between sexual desire and absolute serum testosterone levels. However, other factors, including undergoing gonadectomy, persistence of vaginal bleedings (in TM) and psychological factors may influence sexual desire in transgender people.
SAT-301 Relationship Between Clinicopathological Aspects and MSH6/MSH2 and PD-L1 Expressions in Clinically Nonfunctioning Pituitary Adenomas
Authors: Uraki Shinsuke , Ariyasu Hiroyuki , Doi Asako , Takeshima Ken , Morita Shuhei , Fukuhara Noriaki , Inoshita Naoko , Nishioka Hiroshi , Nakao Naoyuki , Yamada Shozo , Akamizu Takashi
Published: May 2020

Introduction: Mismatch repair (MMR) genes are associated with the MMR mechanism that corrects DNA polymerase misincorporation errors. We analyzed the aggressive pituitary adenomas (PAs) associated with Lynch syndrome due to germline mutation in the MMR gene. Reduced expression of MMR genes mutS homologs 6/2 (MSH6/2) directly promotes PA growth (1, 2). MMR gene expression and programmed cell death 1 ligand 1 (PD-L1) expression are involved in tumor immunity with immune checkpoint inhibitors, but the direct association in PAs is not fully understood. Hypothesis and Objectives: MSH6/2 and PD-L1 expression could affect PA proliferation and invasion by pathological classification of nonfunctioning (NF) PAs because the proliferation and invasiveness differ depending on the PA histological subtype. In this study, we therefore analyzed the correlation between MSH6/2 and PD-L1 mRNA expression levels and clinicopathological factors related to tumor proliferation using human NFPAs. Experimental Design: We performed immunohistochemistry to classify the NFPAs into gonadotroph adenomas (GAs), silent corticotroph adenomas (SCAs), null cell adenomas (NCAs) and pituitary transcription factor 1 (PIT1) lineage PAs according to 2017 WHO classifications. Quantitative analyses were by real-time PCR to detect MSH6/2 and PD-L1 mRNA expressions in NFPAs (n = 89). We also performed statistical analyses of the expressions and clinicopathological factors such as Knosp Grade and histological subtypes. We investigated the effect of MSH6 knockout on cell proliferation and PD-L1 expression in AtT-20ins cells. Major Results: MSH6/2 expression was positively associated with PD-L1 expression. MSH6/2 and PD-L1 expressions are significantly lower in invasive NFPAs with Knosp Grade 3–4 or recurrence than in non-invasive NFPAs with Knosp Grade 1–2. Their expression is significantly lower in SCAs and NCAs than in GAs. Although MSH6/2 expression also tends to be lower, the PD-L1 expression tends to be higher in PIT1 lineage PAs, which is unlike SCAs and NCAs. MSH6 knockout in AtT-20ins significantly decreased PD-L1 expression with cell proliferation promotion. Interpretation of results and Conclusion: MSH6/2 and PD-L1 expressions of SCAs, NCAs, and PIT1 lineage PAs compared to GAs were thought to contribute to their clinically aggressive behaviors. The molecular mechanism of the difference in clinical features of NFPAs was partially elucidated. In particular, reduced expressions of MSH6/2 were thought to be useful for predicting the proliferation and invasiveness of NFPAs.

References: (1) Uraki S et al., Endocr J. 2017;64(9):895–906 (2) Uraki S et al., J Clin Endocrinol Metab. 2018;103(3):1171–1179. Declarations of conflicts of Interest: No authors declare any conflicts of interest.
MON-726 Modifications of FOXO1 and GATA4-NKX2.5 Signaling Induce Human Enteroendocrine Differentiation
Authors: Zeve Daniel Richard , Stas Eric , Shah Manasvi S , Breault David T
Published: May 2020

Enteroendocrine (EE) cells are the most abundant hormone-producing cells in the human body and are vital for metabolism, as well as intestinal and pancreatic function. They have been implicated in the pathogenesis of multiple diseases including diabetes mellitus. Although recent studies have identified multiple signaling pathways (including Wnt, MAPK, BMP and Notch) that can induce low levels of EE cell differentiation, the production of functional human EE cells in vitro remains challenging, making their study and therapeutic utilization difficult. To improve this, we employed the human intestinal organoid culturing system, as it mimics intestinal epithelial homeostasis, allowing for differentiation of multiple epithelial cell types. Using a small scale, directed screen, we targeted multiple transcriptional regulators, using small molecules known to control pancreatic and intestinal development, and hormone production. We chose small molecules instead of gene editing tools to avoid the potential pitfall of off-target mutagenesis.

We found that inhibition of FoxO1 in our organoid culture led to an increase in EE cell differentiation as assessed by EE-specific gene expression, with a 5-10 fold upregulation in expression of ChgA, NeuroD1, and Neurog3 compared to whole mucosal biopsies (P<0.01 for all targets, n=3 per group). Flow cytometry data showed 6-8% of cells produced CHGA, compared to 0.2% in undifferentiated organoids (P<0.0001, n=3 per group), and the 1% typically seen in the duodenum. We also noted a corresponding increase in the production of EE hormones, including glucose-dependent insulinotropic peptide (GIP), serotonin and somatostatin, by qPCR and immunofluorescence. Analysis of conditioned media using ELISA, compared to undifferentiated organoids, revealed increased serotonin (362.6±52.3 vs 167.5±5.1 ng/mL, P=.0037, n=3 per group) and GIP (5.76±1.31 pg/mL vs undetectable, n=3 per group). Independently, upregulation of GATA4-Nkx2.5 also induced EE cell differentiation and hormone production, although to a lesser extent than FoxO1 inhibition. The exception to this was GIP, which showed increased expression and production with GATA4-Nkx2.5 compared to FoxO1 inhibition (20.8±7.4 vs 5.8±1.3 pg/mL, n=3 per group), with a much larger increase when FoxO1 inhibition was followed by GATA4-Nkx2.5 activation (53.4±4.8 pg/mL, n=3). Of note, all experiments were performed in a minimum of three human lines.

Taken together, our data have identified multiple factors, including inhibition of FoxO1 and activation of GATA4-Nkx2.5, that can drive ex vivo human EE cell differentiation, with unique hormone production profiles, when targeted via small molecules. This is a critical first step towards understanding the role of enteroendocrine cells in disease and the development of EE cell-based therapies.
SAT-304 Pituitary Stem Cells May Drive Adenomas Causing Cushing’s Disease
Authors: Asuzu David , Johnson Kory , Elkahloun Abdel , Wu Weiwei , Nieman Lynnette , Stratakis Constantine A , Chittiboina Prashant
Published: May 2020

Introduction:Cell rests of self-renewing Sox2+ progenitor cells have been identified in the normal pituitary glands1, however their role in human pituitary tumorigenesis is not understood. Adrenocorticotropic hormone (ACTH) producing microadenomas that cause Cushing’s disease frequently (~70%) lack pathogenic genetic mutations.2 In mice, targeted expression of oncogenic β-catenin in Sox2+ cells generate microadenomas. Interestingly, the Sox2+ cells reside within the adjacent normal gland and drive adenomas in a paracrine fashion.3 We hypothesized that Sox2+ progenitors in human pituitary gland may drive the formation of microadenomas that cause Cushing’s disease (CD).

Methods:Four ACTH producing adenomas and two non-functional adenomas (NFPA) with separately annotated adjacent normal tissue (henceforward called ‘microenvironment’) were procured for this study (NCT00060541). We performed RNA deep sequencing (RNAseq) and compared expression of lineage-specific markers and progenitor markers using two-sample T-tests after testing for variance equality and using Welch’s approximation for degrees of freedom.

Results:We found expected overexpression of ACTH preprohormone POMC in CD adenomas compared to adjacent microenvironment (?-fold) and NFPA (?-fold). The microenvironment in Cushing’s disease showed increased expression of progenitor markers including SOX2, SOX9, CDH1, GRFA2, and KLF4 compared with microenviroment in NFPA. Likewise, the Cushing’s disease microenvironment showed increased expression ofPOMC (26.98 - fold, P = 0.004) as well as PRLR (FC 17.39, P = 0.006) and GH1 (FC 29.91, P = 0.003) implying that increased Sox2+ progenitors contribute to terminally differentiated corticotrope, lactotroph and somatotroph lineages in-vivo.

Conclusions:We report increased expression of several progenitor markers and concomitant elevation in tissues-specific markers in the microenvironment of Cushing’s disease patients. Our results indicate that increased pituitary progenitors in the microenvironment of human corticotropinomas may signal in paracrine fashion and may contribute to the pathogenesis of Cushing’s disease.

References:1. Cox, B. et al. J. Endocrinol.234, R135-R158 (2017).2. Bi, W. L. et al. Clin. Cancer Res.23, 1841-1851 (2017).3. Andoniadou, C. L. et al. Cell Stem Cell13, 433-445 (2013).
OR03-05 Novel Lipidome Signature in Active Cushing Syndrome Revealed by UHPLC-MS Metabolomics
Authors: Vega-Beyhart Arturo , Iruarrizaga Marta , Garcia-Eguren Guillermo , Pane Adriana , Giró Oriol , Aranda Gloria , Casals Gregori , Porta Mireia Mora , Halperin Irene , Carmona Francesc , Enseñat Joaquim , Vidal Oscar , Hu Ting , Rojo Gemma , Hanzu Felicia Alexandra
Published: May 2020

Background: Alterations in circulating amino acids, polyamines and acylcarnitines have been reported in patients with endogenous chronic hypercortisolism. However, lipid metabolites profiling and its interplay with the serum metabolome and degree of hypercortisolism in patients with active Cushing syndrome (CS) has not been previously assessed. Objective: To identify new metabolomic biomarkers associated with active CS.

Methodology: Multiple UHPLC-MS platforms were used to analyze the metabolome of serum samples obtained from 25 patients with active endogenous CS and 25 controls subjects matched by propensity score (sex, BMI, T2D, DLP, HBP).

Results: Metabolome of CS patients was deeply disrupted with 122 (27%) of the assessed metabolites significantly altered (p adj. <0.05) out of which 5 bile acids resulted with the highest perturbation (> 2-fold decrease). From the altered metabolites, 3 amino acids (AA), 2 acylcarnitines (ACs), 2 ceramides (CER) and 5 glycerophospholipids showed direction of effect independently associated with 24-h urinary free cortisol (MS) levels. A highly discriminant (AUC 96%) metabolome signature (n=59) characterized by lower levels of AA, ACs, polyunsaturated fatty acids (PUFA) and monoglycerophosphocolines (MGPC) together with increased levels of triacyclglycerols (TG), CER, diacylglycerophosphocholines (DGPC) and cholesteryl esters was identified and cross-validated (R2Y= 0.92, Q2Y= 0.68) using PLS-DA VIP scores >1.5. PUFA omega-6, and alanine, aspartate and glutamate metabolism resulted the most impacted canonical pathways (q-stat 19.7, 10.8 (p<0.001). Finally, topological network analysis detected 158 pairwise differential correlations (p <0.005, 10,000-fold permutation) between 141 metabolites due to CS where the acylPC (P-18:1/0:0) resulted a key metabolite in the network (betweenness =0.117 & closeness centrality =0.467).

Conclusion: Active Cushing syndrome leads to a global proatherogenic shift in the circulating ceramides, glycerophospholipids and sphingolipids metabolites which are independently associated to the levels of urinary free cortisol being potential biomarkers of patients’ cardiovascular risk.
SUN-242 Transcriptome of the Amygdala in Normal Cyclic and Acyclic Gilts
Authors: Lents Clay A , Nonneman Dan J , Keel Brittney N
Published: May 2020

Many replacement gilts fail to express estrus, which results from being nonpubertal or behavioral anestrus. Genomic studies identified neuronal and olfaction pathways associated with these reproductive phenotypes. To better understand puberty failure, the transcriptome of the amygdala in nonpubertal, behavioral anestrus and normal cyclic gilts in the early follicular and midluteal phase was evaluated (n = 8/group; mean age = 259 d). An average of 57 million reads were obtained from each of 32 TruSeq mRNA libraries and mapped to Sscrofa 11.1. Differential expression of genes (DEG; adjusted P < 0.05) was determined using DESeq2 and pathway analysis performed with iPathwayGuide. A total of 17,173 annotated genes were expressed (raw read count > 15 in ≥ 8 samples). Comparing amygdala expression in nonpubertal gilts with follicular phase control gilts revealed 6 DEG (3 unannotated) including ARRDC2, ZFAND2A, and LAMC2. The only DEG identified between behavioral anestrus gilts and luteal phase control gilts was PIK3CG. There were 88 DEG in the amygdala of follicular phase gilts compared with luteal phase gilts. Expression of 73 genes was upregulated in the amygdala of follicular phase gilts and 14 genes were more highly expressed in luteal phase gilts. Enriched pathways included TGFβ signaling and ion transport related to GABAergic and glutamatergic neuronal function. Molecular processes for chemokine binding, membrane transporters and receptor signaling through phosphatidylinositol and tyrosine kinases were upregulated in the amygdala of follicular phase gilts. Prominent cellular components included ion channels and integrins necessary for focal adhesions that promote dendritic growth and neuronal synapse. Major differences in the amygdala of prepubertal and behavioral anestrus gilts were not found, with few genes differentially expressed compared to cyclic gilts. Stage of the ovarian cycle majorly impacted gene expression related to increased neuronal activity in the amygdala of follicular phase gilts. USDA is an equal opportunity provider and employer.
SUN-495 Rapid Resolution of Hyperthyroidism Induced Hepatic Dysfunction with Methimazole
Authors: Amir Maryam , Rahhal Marie-Noel , Calles-Escandon Jorge
Published: May 2020

Background:

Hepatic dysfunction in the setting of hyperthyroidism is difficult to diagnose and poses a challenge in therapy, since the classic medications used are potentially hepatotoxic.

Clinical case:

A 51-year-old female patient presented with fatigue, palpitations and tremors. BP 146/65 mmHg, HR 111 bpm and Temp 97.8 F. She was severely thyrotoxic with 3 + DTRs, tremors, enlarged thyroid gland with bruit on auscultation, clear lungs and no lower extremities edema. Blood tests showed TSH <0.003 IU/ml (0.450-5.330 IU/ml), Free T4 5.33 ng/dL (0.45-1.80 ng/dL), Free T3 > 30.0 pg/mL (2.3-4.2 pg/mL). Liver enzymes showed elevation in transaminases with ALT 319 IU/L (7-40 IU/L), AST 330 IU/L (7-40 IU/L) normal total Bilirubin 0.7 mg/dL (0.1-1.5 mg/dL) and Alkaline phosphatase 65 IU/L (40-200 IU/L). Transaminases were also elevated 3 weeks prior to presentation and this was extensively worked up with no identifiable etiology to explain the liver dysfunction. She was started on beta blocker therapy and admitted to the ICU. She had no clinical or echocardiographic evidence of cardiac dysfunction and remained hemodynamically stable. She was started on Methimazole 45 mg daily. The patient improved clinically and a pronounced decline in transaminase levels was documented in the first 72 hours. She was discharged home on day 3 of admission. On follow up visit her transaminases were found to have completely normalized within 14 days.

Discussion:

The diagnosis of elevated transaminases in hyperthyroidism is a challenge. This is due to the possibility of multiple etiologies including decreased cardiac output and/or liver congestion, concomitant primary liver disease or more specifically autoimmune hepatic disease such as primary biliary cirrhosis. (1-2). Incidentally Methimazole has been associated with transient asymptomatic transaminitis typically during the first three months of therapy (3). Our case indicates, that methimazole can be used in patients with a presumed diagnosis of hyperthyroidism induced hepatotoxicity after all possible etiologies are ruled out. Hyperthyroidism as the cause of liver dysfunction can only be entertained after all those etiologies are ruled out and upon resolution of transaminase elevation in conjunction with improvement in the hyperthyroid state itself, as was demonstrated in this case.

Conclusion:

Methimazole can be safely used in patients with severe hyperthyroidism and elevated liver enzymes when all other etiologies of liver dysfunction have been ruled out.

References:

1. Khemichian S, Fong TL. Hepatic dysfunction in hyperthyroidism. Gastroenterol Hepatol (N Y).

2. Elias RM, Dean DS, Barsness GW. Hepatic dysfunction in hospitalized patients with acute thyrotoxicosis: a decade of experience.

3. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. Bethesda (MD): Methimazole
SAT-300 Evading Death: Noxa in Cushing’s Disease Pituitary Adenomas
Authors: Alvarez Reinier , Floros Konstantinos , Johnson Kory , Elkahloun Abdel , Wu Weiwei , Edwards Nancy , Chaudhury Abhik Ray , Nieman Lynnette , Stratakis Constantine , Chittiboina Prashant
Published: May 2020

Introduction: Recurrence of Cushing’s disease (CD) caused by benign pituitary microadenomas are challenging clinical problems. Mechanisms underlying adenoma formation and recurrence remain unknown. PMAIP1 gene codes for Noxa, a Bcl-2 homology 3 (BH3) pro-apoptotic protein frequently downregulated in malignant human tumors.1-6 The role of dysregulated apoptosis remains largely unknown in benign tumors and in CD. We hypothesized that altered expression of Noxa protein is a pro-survival adaptation employed by CD adenomas.

Methods: Syngeneic human pituitary adenoma and adjacent normal gland pairs (n=2), and an additional CD adenoma were analyzed with RNAseq. 10 CD, 1 growth hormone (GH) and 1 non-functioning adenoma (NFPA) underwent immunohistochemical (IHC) analysis for Noxa expression, which was graded by a neuropathologist as 0=none, 1=light, 2=medium, 3=strong. Staining grade represents relative protein expression.

Results: Compared to adjacent normal pituitary tissue, we found that adenomas (n = 3) had a 3.76 fold increase in PMAIP1 mRNA. However, there was attenuated Noxa IHC staining in adenomas compared to normal pituitary in 8 of 10 CD patients (2:3, respectively), but similar staining in 2 of 10 CD patients (2:2 and 2-3:2-3). In GH and NFPA, we found similar patterns of Noxa suppression in the adenomas compared to the normal gland.

Conclusion: Despite elevated PMAIP1 (Noxa) gene expression in adenomas compared to adjacent normal gland in CD, protein expression was reduced in adenomas. This downregulation of Noxa protein expression may contribute to reduced apoptosis of tumor cells. These findings suggest that CD adenomas gain pro-survival advantage by downregulating Noxa protein at post-transcriptional or post-translational level.

References 1. Escobar, D. et al. Cell Death Dis.6, 1-14 (2015).2. Brinkmann, K. et al. Cell Rep.3, 881-891 (2013).3. Liu, Y. L. et al. Oncotarget5, 11237-11251 (2014).4. Dengler, M. A. et al. Cell Death Dis.5, 1-10 (2014).5. Liang, L. et al. J. Oral Pathol. Med.48, 52-59 (2019).6. Tahir, S. K. et al. Cancer Res.67, 1176-1183 (2007).
SAT-022 Adrenal Androgen Production Is Maintained While Ovarian Estrogens Fall Following the Final Menstrual Period in the Study of Women’s Health Across the Nation (SWAN)
Authors: McConnell Daniel S , Lasley Bill L , Crawford Sybil , Gee Nancy A , Auchus Richard Joseph
Published: May 2020

The aim of this study was to clarify changes in sex steroids at the final menstrual period (FMP). We have shown previously that estradiol (E2) declines substantially in the 4-year period around the FMP, but hypothesize that testosterone (T) declines modestly and adrenal Δ5 androgens dehydroepiandrosterone (DHEA) and androstenediol (Adiol) remain unchanged. Methods: Liquid chromatography tandem mass spectrometry (LC-MS/MS) and immunoassay was used in approximately annual samples collected before and following FMP in 1490 women. We estimated time-related changes in each log-transformed androgen using piecewise linear mixed modeling, with knots (slope changes) at FMP-2 yrs and FMP+2 yrs as seen for E2. These models then were re-estimated for subgroups with different time courses identified using group-based trajectory modeling. Results: In the full sample, T was generally stable, although time course varied by subgroup, with a significant decrease of 5%/year in T in [FMP-2yrs, FMP+2yrs] only in the lowest T women. For DHEA and Adiol, declines were similar across all 3 time segments and across subgroups. Mean circulating androgen concentration declined modestly (P> 0.05) from five years before to five years following FMP. However, when stratified only the lowest 7% of circulating T declined significantly (p< 0.05) in the four years surrounding FMP when mean circulating E2 declined. This trajectory divergence of the lower circulating T suggests a different, non-adrenal source that is decreased at FMP which may be useful in clarifying ovarian versus adrenal testosterone production during the post-menopause. Paired results from samples collected before and following FMP in the same subjects indicate mean circulating E2 is less than 5% of mean circulating T suggesting that a relatively large portion of circulating E2 may be largely a result of peripheral conversion of adrenal androgens. Longitudinal LC-MS/MS analyses of circulating E2 and T indicate that the principal change in sex steroid influence at menopause is largely a decrease and dampening of ovarian and not adrenal steroid production.
SUN-313 Depression, Subjective Stress and Serum Osteocalcin Concentrations in People with Type 2 Diabetes Mellitus
Authors: Nguyen Michelle My Linh , Darwish Lina , Major-Orfao Chelsi , Colby-Milley Jessica , Wong Sophie K , Sugamori Kim , Lanctôt Krista L , Herrmann Nathan , Oh Paul I , Yang Pearl , Shah Baiju R , Gilbert Jeremy , Assal Angela , Halperin Ilana Jaye , Mitchell Jane , Swardfager Walter
Published: May 2020

Serum osteocalcin is emerging as a potential marker of glucose homeostasis and risk of type 2 diabetes mellitus (T2DM). In mice, osteocalcin knockouts exhibit depressive-like behaviours but knockouts of a putative osteocalcin receptor, GPR158, are resistant to chronic unpredictable mild stress. Recently, osteocalcin release from bone has been suggested to mediate some aspects of the acute stress response. Here, we assess relationships between serum osteocalcin, depression and perceived stress in people with T2DM. Participants with T2DM were assessed for whether they met the DSM-5 criteria for Major Depressive Disorder using the research version of the Structured Clinical Interview for DSM-5 depression criteria (SCID-5RV). Subjective stress was assessed using the Perceived Stress Scale (PSS) with higher scores indicating greater subjective stress. Serum carboxylated (cOCN) and uncarboxylated (unOCN) osteocalcin were assayed from fasting morning blood by commercial ELISA. Among 87 participants (mean age 62.9±9.5, 52% women), 18 (26%) were experiencing a depressive episode (7 men, 11 women). Both serum unOCN and cOCN were associated with higher PSS scores in participants with depression (unOCN, r=0.566, p=0.014; cOCN, r=0.564, p=0.015) but not in those without depression (unOCN, r=0.002, p=0.985; cOCN, r=0.090, p=0.463). A significant interaction was found between depression and PSS scores predicting serum unOCN in a linear model adjusted for age, sex, body mass index, antidepressant use and HbA1c (F=6.225, p=0.015). The results are consistent with reports that osteocalcin release from bone may be a mediator of stress perception; however, among people with T2DM, this relationship was observed only among those currently experiencing a depressive episode.