bluuebunny/crossref_metadata_2025 huggingface dataset:
SUN-630 Insulin Pumps Versus Multiple Daily Injections in Type 1 Diabetic Pregnancies
Authors: Albanese Isabella , Garfield Natasha
Published: May 2020

Background: Pregnancy is associated with physiological increased resistance to insulin, leading to increased insulin requirements for diabetic women. Poor glycemic control in pregnancy is associated with neonatal and maternal complications. Insulin has been traditionally administered subcutaneously through multi daily injections (MDIs) however, use of insulin pumps or continuous subcutaneous insulin infusion (CSII) has become more widespread. As glycemic control has direct influence on perinatal and maternal outcomes, comparing MDIs and CSII in pregnant women with Type 1 Diabetes Mellitus (DM1) is of interest.

Aim: To investigate whether there is a difference in birth weights in infants born from DM1 mothers who use CSII compared to MDIs.

Methods and Results: This is a retrospective cohort study of women diagnosed with DM1 on either MDIs or CSII whose pregnancies were followed at our institution. The following data was collected on chart review: age, years since DM1 diagnosis, BMI and weight gain at each trimester, total daily insulin dose at delivery, presence of retinopathy or nephropathy, gestational age at delivery, delivery method, presence of hypertension, pre-eclampsia or eclampsia, birth weight, sex of infant and neonatal complications. Preliminary analysis of our currently available data demonstrates that in age-matched groups of women on MDI (N=44) compared to CSII (N=8), there was no significant difference in infant birth weights (3491g ± 760 vs. 3554g ± 666, respectively). There was also no significant difference in neonatal complications (jaundice, hypoglycemia, shoulder dystocia, macrosomia, respiratory distress or prematurity). Women on CSII had been diagnosed with DMI for a significantly longer period of time (20 vs. 14 years) and were on higher total daily doses of insulin per body weight at time of delivery (p<0.05). Despite this, there was no significant difference in weight gain during pregnancy between the groups. There was also no significant difference in the presence of hypertension, pre-eclampsia, eclampsia or in C-section rates.

Discussion: Given the paucity of studies and the increasing use of pump technology among diabetic women, there remains a need for further research comparing the effects of MDIs and pumps on birthweights as well as other neonatal and maternal outcomes.
SAT-058 A Rare Case of Primary Hyperparathyroidism in a Pediatric Patient
Authors: Salazar Natalia , Merz Jeff M , Burdea Liliana , Minutti Carla
Published: May 2020

Introduction: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder in adult patients, but it is rare in pediatric patients. It is usually diagnosed when patients present with symptomatic hypercalcemia or known complications. In children, atypical presentation often results in delayed diagnosis and increased morbidity. We report a 10-year-old boy presenting with abdominal pain and emesis, found to have hypercalcemia and, ultimately, PHPT. His genetic evaluation was notable for a mutation in the RET gene (3.2C>A) of unknown clinical significance. Case presentation: A 10-year-old male with a history of constipation presented to the emergency department with five days of abdominal pain and emesis. Initial workup revealed high serum calcium (Ca) of 17.3 mg/dL (8.7-10.7) and ionized Ca (ICal) of 2.01 mmol/L (0.95-1.32). Further evaluations revealed low phosphorus level 3.5 mg/dL (4.5-6.5) and high parathyroid hormone level (iPTH) of 329.2 pg/mL (8.0-85.0). These findings were consistent with PHPT. Neck US demonstrated a cervical mass in the mid-right thyroid measuring 0.5 x0.3 x0.5cm, questionable for parathyroid adenoma, which was confirmed with 99mTc-MIBI scintigraphy and neck CT. His Ca level initially responded to fluid resuscitation and Lasix, with Ca level decreasing to 13.6. However, on hospital day two, his Ca level became refractory to all interventions, rising to 16 and prompting the use of bisphosphonates. The patient underwent neck exploration with partial parathyroidectomy and lymph node excision. Pathology revealed hypercellular parathyroid tissue consistent with parathyroid hyperplasia. Intraoperatively iPTH was reduced from 3,134.7 to 79.8 and remained within normal limits since. Postoperatively course was uncomplicated, and the patient was discharged home on oral Ca carbonate and vitamin D. A genetic evaluation was remarkable for a change in the RET gene (3.2C>A), a finding of unknown clinical significance. This change has not been seen in association with an individual who fulfills the clinical diagnosis of MEN2A. To further determine if the variant identified in the RET gene is a benign variant, the mother was tested for MEN2A and was negative. Father could not be tested, but family history was significant for thyroid malignancies. The patient is currently doing well four months postoperatively. His Ca level remains normal. Due to the genetic finding and the concern of MEN2A syndrome, the patient is followed closely by pediatric endocrinology and genetics. Conclusion: PHPT is a common endocrine disorder in adults but rare in children. The diagnosis of pediatric PHPT is almost always delayed due to atypical presentation and rarity of the disease. As secondary organ damage is common, a multi-organ assessment is mandatory. Due to the association with other syndromes, a genetic evaluation should be performed.
MON-596 Effects of Angiotensin Type 1 Receptor Blockers (ARBs) on the Expression and Secretion of Adiponectin and Leptin in Human White Adipocytes
Authors: Hattori Naoki , Matsuda Takeshi , Chihara Kazuhisa , Nakatsuji Shunya , Nishida Natsuka , Shimatsu Akira
Published: May 2020

[Introduction]

Adiponectin and leptin are adipokines that are mainly produced in adipocytes and exert various functions. Adiponectin decreases atherosclerosis, oxidative stress, angiogenesis, inflammation, and apoptosis, whereas leptin works oppositely. Angiotensin type-1 receptor (AT1R) blockers (ARBs) are widely used as antihypertensive drugs. Some ARBs are known to activate peroxisome proliferator-activated receptor (PPAR) γ, which is a key regulator of fatty acid metabolism. It is reported that adiponectin secretion increases by pioglitazone, a full agonist of PPARγ, and some ARBs via PPAR γ activation. However, the effects of ARBs on leptin secretion are controversial. The present study aimed to examine the effects of ARBs on the expression and secretion of adiponectin and leptin in human white adipocytes.

[Materials and Methods]

Human white preadipocytes (Promo Cell) were differentiated into mature adipocytes in the medium containing insulin, dexamethasone, thyroxin and isobutylmethylxanthine. Pioglitazone and ARBs including telmisartan, irbesartan, azilsartan, candesartan, losartan, olmesartan and valsartan (1µM) were administered in the culture medium on day 4 and 8. The medium was collected on day 12 and the concentrations of adiponectin and leptin were measured by enzyme immunoassay. Real time PCR was performed to quantitate the mRNA expression of adiponectin and leptin in adipocytes. The experiments were performed in quadruplicate.

[Results]

Pioglitazone significantly increased adiponectin secretion (386.7 ± 133.7 vs. 7.3 ± 1.9 ng/ml in control) from human adipocytes. Among ARBs, adiponectin secretion significantly increased by telmisartan (136.7 ± 16.3 ng/ml) and irbesartan (69.7 ± 23.1 ng/ml), while the other 5 ARBs did not have any influence on adiponectin secretion. Real-time PCR also showed that mRNA expression increased 5.1-fold, 3.8-fold and 1.5-fold by pioglitazone, telmisartan and irbesartan, respectively. Leptin secretion significantly decreased by pioglitazone (27.7 ± 5.0 vs. 82.5 ± 3.8 ng/ml in control). Among ARBs, only telmisartan (38.7 ± 4.2 ng/ml) decreased leptin secretion. Real-time PCR also showed that mRNA expression decreased to be 0.5-fold and 0.7-fold by pioglitazone and telmisartan, respectively. GW9662, a selective antagonist of PPARγ, potently blocked pioglitazone-induced changes of adiponectin and leptin expression and secretion. On the other hand, GW9662 did not reverse telmisartan and irbesartan induced changes.

[Conclusion]

The changes in adiponectin and leptin secretion by pioglitazone are via PPARγ activation, while those by telmisartan and irbesartan may occur in PPARγ-independent manner.
SAT-024 Investigating Racial and Ethnic Comorbidity Patterns of Polycystic Ovary Syndrome
Authors: Actkins Ky’Era , Edwards Digna Velez , Aldrich Melinda , Davis Lea
Published: May 2020

Polycystic ovary syndrome (PCOS) is a highly heterogenous reproductive endocrine disorder that affects up to 15% of women and is one of the leading causes of infertility. However, its genetic etiology remains poorly understood. Additionally, PCOS patients have a greater risk of having metabolic disorders, such as insulin resistance and cardiovascular diseases, but it is estimated that up to 75% of women remain undiagnosed. Delayed treatment and care can exacerbate comorbid conditions and be detrimental to high risk populations like African American and Hispanic women. We aim to characterize genetic and environmental variables contributing to PCOS and understand its shared etiological features with metabolic disorders. To do this, we developed two algorithms to identify diverse PCOS patients using medical records. The broad algorithm used a combination of PCOS-related billing codes (Code Based) and identified a large dataset (N = 8,340) who exhibited diverse PCOS symptoms, while the strict algorithm required PCOS keywords in addition to billing codes (Regex Based). The strict algorithm identified a smaller cohort of patients (N = 4,593) who exhibited more classically diagnoseable PCOS characteristics according to Rotterdam and NIH criteria. Using both datasets, we tested PCOS case status against 1,853 phenotypes in the medical database using a logistic regression model and identified comorbidity patterns for women of European and African descent. We observed that European descent women consistently had more distinct phenotypes associated with PCOS case status than African American women. Next, we examined the interacting effects of self-reported race on PCOS case status and found four significant phenotypes (p < 6.25e-4) in our Regex Based algorithm. African American women with PCOS had greater odds of being diagnosed with “Early onset of delivery” (p = 1.3e-4, OR = 1.86), “Hereditary hemolytic anemias” (p =1.8e-4, OR = 0.65), and “Other hereditary hemolytic anemias” (p = 3.7e-04, OR = 0.90). Meanwhile, European descent women had greater odds of being diagnosed with “Hypertensive chronic kidney disease” (p = 1.7e-04, OR = 0.68). Results show that European and African American women have unique metabolic comorbidity patterns and it may also indicate that clinical PCOS diagnostic standards vary between these groups with possible disparity-causing effects.
SAT-122 Expression of Cell Synthesis and Dna Repair Markers in Meningioma Recurrence or Regrowth
Authors: Leães Rech Carolina Garcia Soares , Silva Camila Batista de Oliveira , Ongaratti Barbara , Trott Geraldine , Minuzzi Ricardo Kunde , Ferreira Nelson Pires , Oliveira Miriam da Costa , Pereira-Lima Júlia Fernanda Semmelmann
Published: May 2020

Meningiomas correspond to 37% of intracranial tumors and are considered the second most common neoplasm of the central nervous system in adults. Most of them are benign with slow growth pattern, common from the fifth decade, more frequent in women and with high recurrence rates. In tumors, there is a reduction in the efficiency of DNA error repair, allowing the proliferation of tumor cells. In this work, we evaluated the protein expression of markers involved in cell synthesis (cyclin D1) and repair of DNA errors (MUTYH, XPF, and XPG) in meningiomas. To date, this is the first study to use the immunohistochemical technique in the evaluation of these repair proteins, relating them to clinical data, tumor variables and recurrence-regrowth free survival. 85 samples were included in the study, patients with a mean age of 52 + 13.3 years, 68% female, in proportion 2:1. Most cases were classified as grade I (79%), meningothelial subtype (38%) and transitional (25%). Regarding surgery, 59% of the patients underwent total resection. Regarding location, the most common was the peripheral (62.2%). Most tumors (64%) were larger than 3cm, with a mean of 3.6±2cm. The median recurrence-regrowth free survival was 67 months (95% CI:57.8-76.6). According to the Kaplan-Meier curve, the recurrence-regrowth free survival rate was 94.4% at 1 year, 76.6% at 2 years and 64.7% at 3 years and 49.4% at 5 years. Grades II and III were prognostic factors for tumor recurrence-regrowth (p<0.05). Cyclin D1 was positive in 92%, 77% in grade I and 23% in grades II and III. A statistically significant relationship was found between cyclin D1 and tumor grade (p = 0.001), with higher expression in grade II and III. Repair proteins were expressed in most meningiomas. MUTYH (63.5%), 43.5% in grades I and 20% in grades II and III, with a significant relationship between grades II and III and, expression 10-50% (p=0.02). Significant association was observed with MUTYH (p=0.001) and XPF (p=0.019). XPF and XPG were associated with grades II and III (p=0.002 and p<0.001) and XPF with size >3cm (p=0.03). There was a positive correlation between XPF and XPG (p= 0.02) and between MUTYH and XPF (p=0.003). XP proteins were related to recurrence-regrowth (p=0.04), but not with recurrence-regrowth free survival. Our results demonstrate the activation of repair pathways and increased cell synthesis in grades II and III in meningiomas. Cellular synthesis and DNA repair markers are important tools to broaden knowledge about the biological behavior of meningiomas.
SAT-375 A 59 Year Old Female with Isolated Vitamin B6 Deficiency and Muscle Spasms
Authors: Zhou Joseph , Effiong Utibe
Published: May 2020

Introduction

Vitamins are essential micronutrients required by biological organisms in small quantities for maintaining basic cellular metabolism. Vitamin B6 is an important co-factor for many biochemical reactions in cellular metabolism related to the synthesis and catabolism of amino acids, fatty acids, neurotransmitters, and organelle-specific compounds, as well as in detoxifying reactive oxygen species within the cell. (1) Due to the role of Vitamin B6 in intracellular metabolism and synthesis of neurotransmitters, deficiency of the vitamin results in impaired transcellular signaling between neurons, and classically presents with muscular convulsions, hyperirritability, and peripheral neuropathy. (2)

Case Presentation

History

We present a case of a 59-year old female with Type 2 diabetes who complained of muscle spasms. She experienced muscle spasms in her feet which have spread proximally to involve her legs. She also admitted to experiencing intermittent spasms in her left arm. The spasms occurred intermittently throughout the day and persist throughout the night, making it difficult for her to fall asleep. She had taken cyclobenzaprine twice daily and tried leg stretches, however her spasms persist. She had also tried baclofen in the past without significant alleviation of her symptoms.

Evaluation

An extensive investigation was conducted including tests for water-soluble vitamins. Her plasma pyridoxal 5-phosphate was 3 mcg/L (reference range 5-50 mcg/L), confirming vitamin B6 deficiency. She was also tested for Vitamins B1, B3, B12 and folate. None of the respective tests indicated deficiencies. Other test results were within normal limits.

Treatment

The patient received standard-dose intramuscular vitamin B6 injections for three weeks followed by oral supplements for 3 months. She was also given cyclobenzaprine (10 mg tablet) three times a day for muscle spasms in her legs. Although she had reported cyclobenzaprine did not significantly alleviate her spasms per se, it produces a sedative effect which improves her tolerance to the spasms and helps her to fall asleep at night.

Conclusion

This case illustrates the rare instance of isolated vitamin B6 deficiency with normal serum levels of other water-soluble vitamins, manifesting as myoclonic spasm involving the legs and arms in the absence of objective polyneuropathy.

References

i1 Parra, Marcelina, Seth Stahl, and Hanjo Hellmann. “Vitamin B6 and its role in cell metabolism and physiology.” Cells 7.7 (2018): 84.

i2 Brown, Mary J., and Kevin Beier. “Vitamin B6 Deficiency (Pyridoxine).” StatPearls [Internet]. StatPearls Publishing, 2018.
MON-210 Role of Female Gender and Subcutaneous Fat in the Positive Association of Obesity with Idiopathic Hyperaldosteronism
Authors: Sawayama Nagisa , Hatano Yu , Ebihara Ken , Ebihara Chihiro , Takahashi Manabu , Nagashima Shuichi , Kurashina Tomoyuki , Okada Kenta , Ishibashi Shun
Published: May 2020

Context: Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. The relationship between PA and various metabolic disorders including obesity, diabetes mellitus and dyslipidemia has been reported. On the other hand, PA consists of two main subtypes: unilateral aldosterone-producing adenoma (APA) and the bilateral idiopathic hyperaldosteronism (IHA), which have different etiologies. Recently, it was reported that the prevalence of obesity was higher in patients with IHA than those with APA, suggesting that there is a link between obesity and the etiology of IHA (Ohno Y et al. J Clin Endocrinol Metab 2018). Furthermore, it has also been reported that female patients with PA are more likely to have IHA than male patients.

Objective: Our objective was to clarify the pathological role of female gender in the positive association of obesity with IHA. Because of the difference of body fat distribution between men and women, we also investigate the contribution of visceral and subcutaneous fats in the pathogenesis of IHA.

Design: This retrospective observational study comprised 117 PA patients (IHA: n = 73, APA: n = 44) diagnosed by adrenal venous sampling between January 2006 and July 2019 at Jichi Medical University Hospital. We compared prevalence of obesity and metabolic parameters including visceral and subcutaneous fat areas measured by computed tomography between patients with IHA and APA by gender. We also compared visceral and subcutaneous fat areas between patients with IHA and APA by the presence of obesity, BMI ≥25 kg/m2 (the diagnosis criteria by Japan Society for the Study of Obesity).

Results: In consistent with previous reports, BMI was significantly higher in patients with IHA than those with APA. However, in male patients, no difference of BMI between IHA and APA was observed. By contrast, in female patients, not only BMI but also both visceral and subcutaneous fat areas were significantly higher in IHA than in APA. Next, we investigated the contribution of visceral and subcutaneous fats in the positive association of obesity with IHA in female patients. Subcutaneous fat area but not visceral fat area was significantly higher in female obese patients with IHA. By contrast, visceral fat area but not subcutaneous fat area was significantly higher in female non-obese patients with IHA.

Conclusions: These results suggest that obesity, especially subcutaneous fat accumulation, contributes to the pathogenesis of IHA in female patients.
SUN-287 A Case of Ectopic Neurohypophysis
Authors: folawewo kehinde Matilda , Hodge MaKenzie , Osman Nada , Zenebe Anteneh Woldetensay , Ganta Vijaya A , Odonkor Wolali Akua-Sabia , Nunlee-Bland Gail Louise , Nunlee-Bland Gail Louise
Published: May 2020

Pituitary stalk interruption syndrome (PSIS) is a congenital disorder of the pituitary gland. Symptoms at presentation may vary widely as this disease presents along a spectrum which includes; ectopic posterior pituitary, interrupted pituitary stalk or aplasia and hypoplasia of the pituitary gland. It is a heterogeneous disorder in terms of radiologic and clinical presentation. It can present clinically as an isolated pituitary hormone deficiency (most common being growth hormone deficiency) or as multihormonal deficiencies.

CASE PRESENTATION

Patient is a 34-year-old woman with history of primary amenorrhea who was evaluated by a gynecologist and was prescribed oral contraceptive pills which lead to her having a menstrual bleed for the first time in her life. She denied any difficulty with smell. She had undergone normal psychomotor milestones and highest level of education was high school. She had normal puberty with normal pubic and axillary hair growth, normal breast development but no menarche. Of note, patient has a short stature, height is 4 feet and 11 inches, and her biological parents are of normal adult height

On evaluation, patient had normal am cortisol, prolactin and thyroid function tests. IGF-1 was significantly low for her age, FSH and LH were inappropriately low for her low estradiol level suggesting hypogonadotropic hypogonadism.

Patient subsequently had an MRI of the pituitary and DXA scan. MRI findings were suggestive of ectopic neurohypophysis. DXA scan showed significant reduction in bone mineral density for age.

Patient is currently being treated with hormonal replacement which is the main modality of treatment for ectopic neurohyphysis. She will need long term follow up as disease progression to pan-hypopituitarism is common.

CONCLUSION

PSIS is a rare syndrome with different phenotypic presentation depending on when the diagnosis is made; therefore, adequate follow up is indicated as the disease can progress from a single hormonal deficiency to pan-hypopituitarism.
SUN-682 Type Two Diabetes Patient in Remission After Twelve Years of Diagnosis
Authors: Shaghouli Amna Ali , Aranky Rola
Published: May 2020

Introduction

Type 2 diabetes (T2D) has been defined as a lifelong condition which is inevitably progressive.1 The idea that beta cell function certainly declines with time in diabetic people who have developed T2D has been definitively disproven.2 It has been recognised that the processes that cause T2D can be reversed and T2D remission can be achieved.2

Many studies show that, by changing life style dramatically, controlling diabetes can improve significantly and a significant proportion of patients can also reduce or come off their glucose-lowering therapies.3 This has been formally proven in DIRECT, with clear evidence of gradual continuing improvement in beta cell functional capacity over at least 12 months.4 Remission was linked to weight loss, as two third of those who lost more than 10kg were in remission after two years.4

Methods

A case study was done on a 66 years old male, who is diabetic for the last 12 years, with other comorbidities: hypertension and hypercholesterolemia.

He presented with Hemoglobin A1C (HbA1c) of 7.4% with BMI of 37.7 kg/m2 on four oral hypoglycaemic agents and basal insulin of 20 units per day.

His treatment was changed by adding Glucagon-like peptide-1 receptor agonists (GLP-1 RA) for better glycemic control and weight reduction in a setting of a multidisciplinary team approach, including endocrinologist, diabetes educator, dietitian and physical trainer.

Results

Over the last one year and two months, patient was able to stop all his diabetes medication including GLP-1 RA. Over three years follow ups patient achieved weight reduction of 17.3% with HbA1c of 6.5% and additional other metabolic factor benefits.

Conclusion

Even with 12 years of diabetes, reversibility of T2D can still be achieved with weight reduction of over 15%. We will wait for another 10 months to reconfirm our data for two years remission.

References

1. Steven S, Taylor R. Restoring normoglycaemia by use of a very low calorie diet in long-and short-duration Type 2 diabetes. Diabetic Medicine. 2015 Sep;32(9):1149-55.

2. Nagi D, Hambling C, Taylor R. Remission of type 2 diabetes: a position statement from the Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS). British Journal of Diabetes. 2019 Jun 27;19(1):73-6.

3. Wing RR, Blair E, Marcus M, Epstein LH, Harvey J. Year-long weight loss treatment for obese patients with type II diabetes: does including an intermittent very-low-calorie diet improve outcome?. The American journal of medicine. 1994 Oct 1;97(4):354-62.

4. Taylor R, Al-Mrabeh A, Zhyzhneuskaya S, Peters C, Barnes AC, Aribisala BS, Hollingsworth KG, Mathers JC, Sattar N, Lean ME. Remission of human type 2 diabetes requires decrease in liver and pancreas fat content but is dependent upon capacity for β cell recovery. Cell metabolism. 2018 Oct 2;28(4):547-56.
SAT-388 Dry Cough as Only Sign of a Parathyroid Adenoma Producer of PTH
Authors: Selman-Geara Antonio , Benitez-Camporro Antonio , Defillo-Guerrero Guillermo , Ibrahim Ammar , Redondo, Cytopathologist Yasmin , Rodriguez L , Selman-Fermin Antoine , Selman-Fermin Anyel I
Published: May 2020

BACKGROUND: The parathyroid adenoma producing an excess of PTH is characterized by hypercalcemia, asthenia, physical weakness and renal lithiasis. This clinical case is presented only with a dry (non-productive) cough sign of long duration.CASE: 51-year-old female born in Padre Las Casas, D.R. presenting with chief complain of dry cough for about four years. Clinical findings: (03/13/2019) Height 62”, Weight 142 lbs, Temperature 36.2 Celsius, BP 90/60 mmHg, RR 16 rpm, HR 60 bpm, on her neck no adenopathies or thyroid changes. Occasional coughing. A sonographic evaluation of the neck (04/09/2019) reveals a solid, heterogeneous nodular image of 0.7 cm x 0.5 cm in the left lobe of the Thyroid (Fig. 1) which by FNAB (04/10/2019) showed a benign adenomatoid node with cystic changes (Bethesda II) (Fig. 2). TEST: (03/20/2019) anti-TG 0.10 IU/mL (NV -115), anti-TPO 9.00 IU/mL (NV -34), TG 9.41 (NV -78 ng/mL), TSH 0.34 μIU/mL (VN 0.27-4.20), free T3 2.05 pg/mL (NV 2.04-4.40), total T3 0.74 ng/mL (NV 0.83-2.00), total T4 8.46 μg/dL (NV 5.1-14.1), free T4 1.61 ng/dL (NV 0.93-1.71) Calcium 10.4 mg/dL (NV 8.1-10.4), Phosphorus 2.6 mg/dL (NV 2.5-4.5), PTH-Intact 157 pg/mL (NV 14.5-87.1) Thyroid-Parathyroid scintigraphy (Sestamibi-Technetium 99mTc04: 15 mCi) (04/23/2019) shows lower left Parathyroid Adenoma (Fig. 3). She undergoes surgery (05/23/2019) removing the left thyroid lobe and left inferior parathyroid gland whose pathology shows chronic nodular colloid goiter, with areas of hemorrhage. Parathyroid adenoma of main cells (Fig. 4-5). Post-surgical TEST (06/24/2019) PTH-intact 69.0 pg/mL (NV 14.5-87.1), Calcium 8.6 mg/dL (NV 8.1-10.4), Phosphorus 2.7 mg/dL (NV 2.5-4.5), anti-TG 10.0 IU/mL (NV <115), anti-TPO 9.00 IU/mL (NV <34), TG 8.92 ng/mL (NV <78), total T3 0.68 ng/mL (NV 0.83-2.00), free T3 1.95 pg/mL (NV 2.04-4.40), total T4 6.40 μg/dL (NV 5.1-14.1), free T4 1.02 ng/dL (NV 0.93-1.71). Post-surgical clinical evaluation (06/21/2019) Weight 142 lbs, Temperature 36.5 Celsius, BP 110/70 mmHg, RR 16 rpm, HR 60 bpm. Patient has not shown signs of coughing. Last TESTS (10/20/2019) Calcium 9.40 mg/dL, Phosphorus 3.10 mg/dL, PTH-intact 24.40 pg/mL, TG 11.90 ng/mL, total T4 6.80 μg/dL, free T4 1.23 ng/dL, total T3 0.88 ng/mL, free T3 2.66 pg/mL, anti-TPO 11.14 IU/mL, anti-TG 10 IU/mL. CONCLUSIONS: Lower left (benign) parathyroid adenoma whose clinical manifestations are not common. Dry (non-productive) cough is not known as a manifestation of elevated PTH-intact. Calcium and Phosphorus levels in normal values. In addition, histological alterations of the left thyroid lobe of benign character with few manifestations of hormonal alterations and normal antibodies. It is of crucial clinical importance to observe and document more cases with similar presentation in order to identify the possible causes of cough with an elevated PTH manifestation.
SUN-038 Social and Psychological Aspects of Partial Androgen Insensitivity Syndrome, Therapeutic Challenges
Authors: Masood Faryal T , Kiran Zareen
Published: May 2020

Background: Partial Androgen Insensitivity Syndrome (PAIS) is a rare congenital condition with incongruence of chromosomal, gonadal and phenotypic sex and classified as differences of sex development. Distinct from complete Androgen Insensitivity by the presence of ambiguous genitals in a 46, XY individual with normal testis development and partial responsiveness to androgens.

Clinical Case: 18 years phenotypic female presented with primary amenorrhea and ambiguous genitalia with poor secondary sexual characteristics after puberty. Born out of a consanguineous marriage, normal vaginal delivery conducted by midwife at home in a small village, who informed a female with ambiguous genital though. Since childhood she uses to dress up in female attire. She has 5 siblings, two brothers and three sisters, one year back she got engaged to her distant cousin and was about to get married when one of her younger sister now 8 years having similar problem alarmed family to report before the wedlock.Vitals:Weight 55kg,Height 167cm,Physical, biochemical, chromosomal testing and imaging revealed:micropenis 3cm(N=8cm) with hypospadias, a small blind vaginal orifice, hormones within normal male ranges, Karyotype: XY, MRI revealed no female internal organs or prostate gland, left testis seen in partly formed scrotal sac (4.6x2.5cm) right in superficial inguinal region (2.7x1.9cm),normal testes size(4x3cm), bilateral cavernous tissue,respectively. Findings suggested phenotypic female with PAIS. Further investigations could not be carried out due to poor affordability and non-availability of Genetic testing facility. Management: Male gender was preferred (after discussion with urologist and consent of the patient and the family) Assigning the gender, health-related quality of life (QoL), social and psychological well-being, and affective disorders, like fertility and sexual functions in PAIS were discussed. Psychometric data was obtained through psychological questionnaires: Beck Depression Inventory & Hospital Anxiety and Depression Scale revealed moderate depression. An important pre-decision analysis regarding the potential impact of clinical decisions such as the type and timing of genital surgeries on patient’s life is missing due to absence of a multidisciplinary team for counseling and decision making.

Conclusion: After spending 18.yrs as a phenotypic female the patient and her family experienced considerable emotional distress. In our culture and society these types of cases are seldom reported. We as medical professionals need to be sensitive to the social and psychological wellbeing of patients so that they can be settled and acceptable in their part of the world.
SAT-206 A Sweet and Salty Milieu: The Utility of CT in Bilateral Adrenal Hemorrhage
Authors: Tavares Matthew V , Sittol Rani Delraj , Chang Sang-Min , Otuonye Gene , Barnes Tanganyika
Published: May 2020

Introduction: Bilateral adrenal hemorrhage (BAH) is seldomly recognized as a cause of adrenal insufficiency due to nonspecific clinical manifestations within the milieu of major concurrent illnesses. CT abdomen is the investigation of choice to evaluate acute adrenal crisis.

Clinical Case: A 68 year old female with systemic lupus erythematosus, anti-phospholipid antibody syndrome (APS) complicated by multiple strokes, on warfarin, and recent hip fracture presented with confusion, lethargy, fever, and cough. On exam she was febrile, tachycardic, tachypneic, disoriented with right sided hemiparesis, and crepitations on lung auscultation. Lab results were significant for leukocytosis of 14K/uL, hemoglobin (Hb) 9.9g/dL, INR 3.8, azotemia, normal electrolytes, and glucose 67mg/dL. Blood and urine cultures were negative. Anti-dsDNA, C3, and C4 were normal. CT chest showed right lower lobe infiltrates and bronchial debris. She was treated with antibiotics and bronchoscopy with mucus plug removal. Her lethargy and confusion persisted. MRI brain was negative for acute event. Hb fell to 7g/dL; managed conservatively with i.v. iron. CT abdomen showed BAH both measuring 3.5x3.5cm; AM cortisol was 5.5 mcg/dL. Warfarin was reversed with vitamin K; hydrocortisone 50mg q8h was started with improvement in her mental status. ACTH levels were <5pg/ml; ACTH stimulation testing was deferred as steroids were started emergently. Repeat CT showed stable BAH, AM cortisol increased to 19.4mcg/dL, and Hb stable at 8g/dL. She was discharged on hydrocortisone 10mg twice daily.

Discussion: Trauma, corticotropin stimulation during stress, anticoagulation therapy, and APS inducing adrenal venous thrombosis have been identified as risk factors that predispose to BAH. There is a lack of consensus regarding normal cortisol levels in critical illness. Fluctuations in serum cortisol levels are frequent and not necessarily indicative of definite injury to the adrenal gland. CT abdomen, the investigation of choice in the acute setting, has a heterogeneous, high density appearance; the presence of an underlying adrenal mass cannot be excluded. BAH appears as diminished attenuation of the adrenal gland with respect to the adjacent tissues, along with thickening of the ipsilateral crura due to retroperitoneal extension of blood (1). MRI has a greater accuracy for identifying BAH in comparison to CT as it can discern adrenal hematoma from adjacent necrotic tissue and determine the acuity of the hematoma.

Conclusion: The nonspecific clinical manifestations of BAH are frequently inseparable from those of the concurrent major illness. The diagnosis requires a high index of suspicion, initiation of prompt steroid replacement, and confirmation by CT abdomen.

References: (1) Fatima, Z., Tariq, U., Khan, A., et. Al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018 Jun; 10(6): e2830. doi: 10.7759/cureus.2830
SAT-127 Localization and Treatment of the Ectopic ACTH Syndrome Using Somatostatin Analogues
Authors: Mago Sheena , Malchoff Carl , Karimeddini David
Published: May 2020

Ectopic ACTH syndrome (EAS) is a rare disorder with a high morbidity and mortality due to the sequelae of severe hypercortisolism and possible underlying carcinoma. It is caused by various tumors, some originating from neuroendocrine cells. Optimal management includes localization and removal of the ectopic ACTH source. About 80% of these tumors have somatostatin (SS) receptors, so that SS analogues may be useful in the localization and treatment. This case demonstrates the use of SS analogues in localization and treatment of EAS.

A 49-year-old female presented with 7 months of worsening Cushingoid features including rounded plethoric face, full supraclavicular fat pads, facial hair growth, multiple bruises, violaceous abdominal striae, kyphoscoliosis, 4+ peripheral edema, weight gain, hypertension (190/110 mmHg) and thoracic compression fractures. AM plasma ACTH concentration was 333 pg/mL (nl = 6 - 58 pg/mL); serum concentration cortisol was 71.4 mcg/dL (nl = 7 - 23 mcg/dL) and serum potassium concentration was 1.2 mmol/L (nl = 3.6 - 5.1 mmol/L). A 24-hour urine cortisol could not accurately be obtained. High dose 8 mg overnight dexamethasone testing demonstrated suppression of serum cortisol concentration from 71.4 to 6.3 mcg/dL, suggesting pituitary Cushing disease. Pituitary MRI scan revealed a 2.5 mm disc shaped cystic focus suggesting a Rathke’s cleft cyst. No central-to-peripheral ACTH gradient was present on bilateral inferior petrosal sinus sampling suggesting an ectopic ACTH source. There was a 1.2 x 1.0 cm nodule in the left lower lung lobe on CT chest. A gallium-68 dotatate PET/CT scan demonstrated enhancement of this same lung lesion and mild uptake in the left inferior hilum, suggesting a neuroendocrine lung tumor with possible metastases to lymph nodes. Biopsy and resection of the lesion was deferred until after control of her hypercortisolism. 30mg of Sandostatin LAR was started every 4 weeks to control the ectopic ACTH secretion and to confirm that the SS analogue positive lung lesion was the cause of the EAS. Sandsostatin LAR therapy over the next 12 weeks resulted in a steady clinical and biochemical improvement with a decrease in serum cortisol to 9.7 mcg/dL, control of hypertension (108/64 mmHg), weight loss of 6 pounds, and resolution of supraclavicular fat pads, hypokalemia, and peripheral edema. This confirmed our impression that the neuroendocrine lung tumor was the ACTH source.

In summary, this patient with EAS had severe clinical manifestations of hypercortisolism and could not safely undergo surgical intervention. This case demonstrates the value of SS analogues (gallium-68 dotatate PET/CT and Sandostatin LAR) in localizing and confirming the source of ectopic ACTH production and markedly improving the clinical and biochemical features of the EAS.
SUN-300 Improvement in Cardiovascular Risk Factors in Long Term Follow up of Hypopituitary Septagenarian and Octagenarian Patients
Authors: Rosa Isabella Naves , Soares Alexandre Anderson S M , Naves Luciana Ansaneli
Published: May 2020

Background: Hypopituitarism in the elderly population is an underdiagnosed condition and may increase co-morbidities in glucose metabolism, dyslipidemia and cardiovascular risk factors. Pituitary macroadenomas are benign tumors, which prevalence is unknown in aged people, and is frequently associated to impairment in pituitary function. Objective: The aim of this study is to identify cardiovascular risk factors in hypopituitary septagenarians and octagenarians by diagnosis and after long term follow up of pituitary dysfunction. Methods: This is a retrospective observational study and the patients were recruited and selected from a service registry in a tertiary medical center. We included patients aged from 70-99 years with the diagnosis of pituitary macroadenomas, evaluated hormonal and biochemical parameters, cardiovascular risk scores were calculated by diagnosis and compared after long term follow up. All patients signed informed consent. Results: Thirty five patients were included, 21 patients aged 70-75 years (72.61 yo), 7 patients 76-80 years (77.28yo), 7 patients 81-99 years (89.28 yo). All tumors were macroadenomas, 40% of them Non Functioning Pituitary Macroadenomas, mean maximal diameter 3.4 cm (2.9-.4.3), 40% of them submitted to surgery, 14% adjuvant radiotherapy, 20% presented previous apoplexy. Co-morbidities were frequent by diagnosis, 85.71% presented Hypertension, 37.14% Diabetes, 62.8% Hypercholesterolemia and 45.71% Hypertriglyceridemia. Hypopituitarism was present in 71.42%, GH deficiency in 37.14%, hypogonadism in 60%, central hypothyroidism in 54.28%, adrenal insufficiency in 31.42%, 51.42 % presented more than two combined deficiencies. Analysis of cardiovascular risk prediction in total cohort showed, 57.14% of patients presented reduction of Framingham Score and 45.71% in Coronary Calcium Score, during mean time follow up of 13.09 years (3-32 years after diagnosis). According to ages, Framingham score and Coronary Calcium Score reduced respectively in 66% and 33.3% (70-75 yo), 57.15% and 85.71% (76-80 yo) and 42.85% and 28.57% (81-99 yo), during long term follow up. Discussion and Conclusion: In this study, most of hypopituitary aged patients presented reduction of cardiovascular risk factors during long term treatment and follow up, despite replacement with corticosteroids and gonadal steroids. Considering the importance of early diagnosis and the lack of data observed in the medical literature, larger scale studies should be performed with the objective to assess of the risk benefit ratio of hormonal replacement in metabolic control in septagenarian and octogenarian patients.
SAT-666 Possible Amelioration of Diabetic State After Intravesical BCG Instillations for Bladder Cancer
Authors: Havranova Jana , Gallagher Thomas , Arastu Mohammad Ishaq
Published: May 2020

Introduction - Current research provides strong evidence that intradermal Bacillus Calmette-Guerin (BCG) vaccination improves glucose metabolism by a mechanism of switching oxidative phosphorylation to aerobic glycolysis inducing a state of high glucose utilization. We present a case that demonstrates improvement in blood sugar levels upon administration of a series of intravesical BCG instillations. There is no research, in current literature, correlating blood sugars lowering after intravesical administration of BCG vaccines.

Case Description - An 81 years old male with a medical history of type 2 diabetes mellitus, coronary artery disease, and bladder cancer underwent a series of BCG instillations, as therapy for his bladder cancer. He underwent BCG treatments according the Southwest oncology protocol for bladder cancer. During his BCG treatments, the patient was on Humalog 75/25, 30 units twice a day. Upon completion of his treatments, the patient experienced an episode of hypoglycemia that required hospitalization. His insulin regimen was decreased from 30 to 25 units BID. His A1C at the time of diagnosis was 8.7% and after insulin adjustments declined to 8.1%. We are reviewing a list of type II diabetic patients with bladder cancer who were treated with BCG and analyzing blood sugars before and after BCG exposure. We hypothesize that BCG vaccination precipitated the improvement in his blood sugars.

Conclusion - Additional studies on BCG vaccinated, diabetic, bladder cancer patients are needed for confirmation of this effect. Our case illustrates a probable reduction in blood sugars attributable to his BCG vaccinations. Research suggests that intradermal BCG switches cellular metabolism from oxidative phosphorylation to early aerobic glycolysis. Another effect of BCG is the increasing levels of tumor necrosis factor (TNF) that leads to elimination of self-reactive white blood cells and inducing regulatory T cells. More research is needed to confirm whether intravesical administration of BCG has the same effect as intradermal BCG vaccination, which would have a potential impact on the clinical management of both type 1 and type 2 diabetic patients.
SUN-027 Testicular Regression Syndrome, an Underdiagnosed Cause of Hypergonadotropic Hypogonadism
Authors: Canales-Ramos Nicolle M , Burgos-Ortega Nydia I , Grana-Santini Alberto J , Colon-Castellano Janet M , Gracia-Ramis Alvaro , Nieves-Rivera Francisco , Alvarado Milliette , Gonzalez-Rodriguez Loida A , Ramirez-Vick Margarita
Published: May 2020

Background: Testicular regression syndrome (TRS), also known as vanishing testes syndrome, is a condition of 46, XY males presenting with male phenotypic genitalia and testicular absence. Normal testes are thought to have once existed in fetal life and subsequently atrophied following a catastrophic event. It may present as partial or complete absence of testicular tissue. Fibrotic remnants are commonly found upon surgical exploration.

Case: This is the case of a 20-year-old male with a birth-diagnosis of primary hypogonadism. The patient was born prematurely at 5 months following a motor vehicle accident that resulted in his mother’s death. Neonatal evaluation for cryptorchidism revealed no radiological evidence of intra-abdominal testicular mass. Referral to a pediatric-endocrinologist was done at early childhood. Testosterone replacement was started at 12 years of age and pubarche was adequate. After surgical exploration, a testicular remnant was surgically removed. Pathology report revealed fibrotic tissue, yet no histological testicular tissue was found. Due to lack of testes in the scrotum, testicular prosthesis was implanted at age 14, but the etiology of the hypogonadism was never elucidated. The patient was initially seen in our adult-endocrinology clinics at age 21. Upon evaluation, secondary sex characteristics were adequate for age. Penile length was of 3.5 inches. Bilateral testicular prostheses were palpable, and no gynecomastia was present. Despite testosterone replacement, total testosterone was 3.38 ng/ml (n; 2.41-8.27 ng/ml), FSH was 106 mIU/ml (n; 1.4-18.1 mIU/ml) and LH was 34.7 mIU/ml ml (n; 1.5-9.3 miu/ml). Based on history, laboratory workup and surgical pathology, TRS was presumed as the etiology of this patient’s hypogonadism. Testosterone therapy was adjusted to reach physiological expected levels.

Conclusion: TRS is an underdiagnosed cause of hypergonadotropic hypogonadism. It is supposed that the initial embryologic development was normal, followed by a vascular accident. There is no clear recommended approach for evaluating a patient once the diagnosis of TRS is suspected. Diagnostic methods may include hormonal and karyotype testing, imaging, and surgical exploration. Furthermore, although clinical recommendations have been published for other disorders of sex development, TRS management has been understudied. Testosterone replacement therapy at the typical time of puberty ensures the development of secondary sexual characteristics, bone health and pubertal growth. Unlike Klinefelter syndrome and cryptorchidism, TRS has not been associated with increased risk of cancer. Thus, it is important to establish the etiology to avoid invasive and unnecessary workup, which will result in psychological distress and excessive healthcare costs.
MON-028 Chronic Resveratrol Exposure Improves Glucose Homeostasis and Cardiac Function in a Rat Model of Polycystic Ovarian Syndrome
Authors: Molina Rogelio Enrique , Shao Tiffany , Randhawa Harmanprit , Hoang Vanessa , Vyas Arpita Kalla
Published: May 2020

Polycystic ovary syndrome (PCOS) is the commonest endocrinopathy in women of reproductive age, with a prevalence of 5-8%. Long-term complications seen in PCOS include cardiovascular disease and type 2 Diabetes Mellitus. Current therapies do not completely address the cardiometabolic perturbations seen in women with PCOS. Resveratrol (RSV), a natural polyphenol, is shown to have beneficial cardio-metabolic effects in various pathological conditions including that on insulin sensitivity, cardiovascular function. In-vitro studies suggest it’s beneficial effects on ovarian function as well. Therefore, we hypothesized that chronic exposure to RSV would improve both cardiovascular and metabolic phenotypes in PCOS. To test this hypothesis we used an established rat model of PCOS that develops metabolic derangement and irregular cycles. A 7.5 mg (90-day release) dihydrotestosterone (DHT) pellet providing a daily dose of 83 mcg was implanted in 5-week-old female rats. Studies were also conducted on littermate matched controls (C) with no DHT implant. A subgroup of the control and DHT treated rats (n=6 per group) received a 0.84 g/kg dose of resveratrol (RSV) in their chow starting at age 5 weeks. At 8 weeks, animals were weighed weekly (n=6 per group). Oral glucose tolerance test (OGTT n=6 per group) and cardiac echocardiogram (C n=12, C+RSV n=6, DHT n=10, DHT+RSV n=6) were conducted at 16-weeks of age. Body weight increased significantly in DHT treated rats compared to C between 8 and 16 weeks (40 vs 22 grams, p <0.001). RSV treatment did not mitigate the effects of DHT on body weight (34 vs 40 grams, p>0.5). There was significantly higher glucose excursion at 30 minutes post glucose load in both DHT (148± 7.4 mg/dl) and DHT+RSV (139± 7.4 mg/dl) compared to C group (121± 13 mg/dl, p<0.001, p=0.03 respectively). However, by 60 and 90 minutes only DHT group had a significantly higher glucose excursion compared to both DHT+RSV and C groups (131± 4.1,124± 5.7,110 ± 5.9 mg/dl, p=0.015,p=0.21 respectively); 90min (118±5.8,110±4.7,96±4.2 mg/dl, p<0.01,p=0.09 respectively). By 120 minutes, no significant difference in glucose levels existed between groups. Cardiac echocardiogram showed significantly lower mitral valve E/A ratio (and increased MV isovolumic relaxation time (IVRT) in DHT group compared to C. RSV treatment reversed these changes. In conclusion, RSV improved glucose homeostasis and diastolic dysfunction in the DHT induced rodent model of PCOS and may serve as a novel treatment option targeting the cardiometabolic derangement seen in PCOS. Further studies elucidating the mechanisms underlying the beneficial effects of RSV on cardio-metabolic phenotype in this PCOS rodent model is warranted.