bluuebunny/crossref_metadata_2025 huggingface dataset:
SAT-170 Clinical Course of Adrenal Myelolipoma: A Long-Term Longitudinal Follow-Up Study
Authors: Hamidi Oksana , Raman Ram Narayan , Lazik Natalia , Ariza-Iniguez Nicole , McKenzie Travis J , Bancos Irina
Published: May 2020

Myelolipoma is the second most common adrenal tumor. Yet, systematic approach to these tumors remains poorly defined. Thus, we aimed to describe natural history of myelolipoma and to identify predictors of tumor growth and need for surgery. We conducted a retrospective longitudinal follow-up study of consecutive patients with myelolipoma. A total of 321 myelolipomas (median size, 2.3 cm [range, 0.5-18.0]) were diagnosed in 305 patients at median age of 63 years (25-87). Most myelolipomas were discovered incidentally (86.6%), whereas others were discovered on imaging done for cancer staging (8.8%) or during workup of mass effect symptoms (4.6%). Median duration of follow-up was 54 months (range, 0.03-267). Compared with myelolipomas <6 cm, tumors ≥6 cm were more likely to be right-sided (59% vs 41%, P=0.02), bilateral (21% vs 3%, P <.0001), cause mass effects symptoms (32% vs 0%, P<.0001), have radiographic hemorrhagic changes (14% vs 1%, P<.0001), and undergo adrenalectomy (52% vs 5%, P<.0001). There was no difference in sex or age at diagnosis between the groups. Hemorrhagic changes were noted in 9 (3.0%) patients with median tumor size of 7.0 cm (range, 1.8-18.0). Concomitant adrenal hormone excess was diagnosed in 12/126 (9.5%) patients. Primary aldosteronism was noted in 9 patients: due to concomitant ipsilateral (n=3) or contralateral adrenocortical adenoma (n=3), or bilateral idiopathic adrenal hyperplasia (n=3). Autonomous cortisol excess was noted in 3 patients: due to concomitant contralateral (n=2) or ipsilateral adrenocortical adenoma (n=1). Of 162 patients with ≥6 months of imaging follow-up, tumor size change ranged from -10 to 115 mm (median, 0 mm) and tumor growth rate ranged from -5.6 to 140 mm/year (median, 0 mm/year). Tumor growth ≥1.0 cm (n=26, 16.0%) was associated with larger initial tumor size (3.6 vs 2.3 cm, P=0.02) and hemorrhagic changes on imaging (12% vs 2%, P=0.007), compared with <1 cm size change. Myelolipomas with ≥1.0 cm growth were more likely to undergo adrenalectomy (35% vs 8%, P<.0001). Among 37 (12%) patients that underwent adrenalectomy for myelolipoma, surgical indications included: large tumor size/tumor growth (32%), diagnostic surgery (27%), mass effect symptoms (14%), concomitant ipsilateral tumor leading to hormonal excess (11%), acute hemorrhage (8%), and concomitant resection during non-adrenal surgery (8%). In conclusion, most myelolipomas are discovered incidentally, whereas myelolipomas ≥6 are more likely to cause mass effect symptoms, have radiographic hemorrhagic changes, and more commonly undergo resection. Hormonal excess is rare and is usually attributed to concomitant adrenocortical adenoma or hyperplasia. Tumor growth ≥1.0 cm is associated with larger myelolipoma and presence of hemorrhagic changes. Surgical resection should be considered in symptomatic patients with large tumors, evidence of hemorrhage, or tumor growth.
SUN-616 Poor Diagnostic Concordance Between Fasting Plasma Glucose and Glycosylated Hemoglobin in a Black South African Population
Authors: Wade Alisha N , Crowther Nigel , Gomez-Olive F Xavier , Wagner Ryan G , Manne-Goehler Jennifer , Berkman Lisa , Salomon Joshua A , George Jaya , Gaziano Thomas , Cappola Anne Rentoumis , Tollman Stephen
Published: May 2020

Background: While elevations in fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) are both recognized by the American Diabetes Association (ADA) as diagnostic of hyperglycemia, previous comparisons of these tests have demonstrated discordant individual classifications and population estimates. This may be due to additional postprandial glycemia reflected by HbA1c and, in African-descent populations, to non-glycemic factors that contribute to higher HbA1c at any given level of glycemia. We hypothesized that glycemic classifications based on FPG or HbA1c would differ in a Black South African population and investigated factors associated with discordance.

Methods: 889 Black adults with previously undiagnosed diabetes, aged 40-79 years, from the population-based Health and Ageing in Africa: a Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) cohort were included. Concordance between ADA FPG (normoglycemia [NG] <100 mg/dl, prediabetes [pre-DM] 100-125 mg/dl, diabetes [DM] ≥ 126 mg/dl) and HbA1c (NG <5.7%, pre-DM 5.7-6.4%, DM ≥ 6.5%) classifications was assessed using Cohen’s kappa statistic and logistic regression models were used to identify predictors of discordance.

Results: Median age was 55 years (IQR 49-62) and 49.3% of the sample was male. Median glucose was 86.4 mg/dl and median HbA1c was 5.4%. Pre-DM, as defined by HbA1c, was present in 204 participants (22.9%), while FPG-defined pre-DM was present in 122 (13.7%). DM defined by HbA1c was present in 146 (16.4%), while FPG-defined DM was present in 36 (4.0%). Concordance between the two tests was poor (kappa statistic 0.18; 95%CI 0.13-0.24). Self-reported history of tuberculosis (OR 1.90, p=0.026) and higher HbA1c (OR 4.70, p<0.001) were associated with increased likelihood of discordance, whereas higher fasting glucose was associated with decreased likelihood of discordance (OR 0.58, p<0.001). There was no association between discordance and hemoglobin, HIV status, BMI, waist circumference or hip circumference.

Conclusion: FPG and HbA1c exhibit poor concordance in classifying hyperglycemia in this Black South African population, with HbA1c-based definitions identifying higher prevalences of pre-DM and DM. Further work is needed to confirm whether these discrepancies are due solely to elevations in postprandial glucose. In the interim, clinicians should consider confirming elevated HbA1c concentrations with oral glucose tolerance testing, particularly in those with a history of tuberculosis, prior to making a diagnosis of DM in this population.
SUN-384 A Dedicated Primary Fracture Prevention Program Decreased Low Trauma Hip Fracture Rates over Six Years
Authors: Grotzke Marissa Paige , Rosenblum Yanina
Published: May 2020

BACKGROUND: Improvements in secondary prevention of osteoporotic fractures are widely reported following the dissemination of Fracture Liaison Services, however, few models for the primary prevention of such fractures have been described. Available published data indicates osteoporosis screening rates in the United States, most significantly in men, remain consistently less than 20% (Cheng N, Green ME). We have previously published how an interdisciplinary Bone Health Team (BHT) improves screening and treatment initiation rates in the outpatient setting. Here we describe the changes in low trauma hip fracture hospitalizations in the six years since initiation of BHT screenings.

METHODS: The BHT began osteoporosis screening in February 2013. Hip fracture admission rates at our facility for each year starting in 2007 were assessed utilizing codes ICD 9 820*/ICD 10 S72.*; our facility is not a trauma center and receives no trauma injuries. Data was divided into a period from October 2007 to September 2013 and October 2013 to September 2019, the latter period based upon the average timeline from identification to treatment initiation and expected efficacy for the first screening group.

RESULTS: From October 2007 to September 2013 there were 216 individuals admitted with a new hip fracture diagnosis, representing 0.54% of the averaged 40,362 individuals served by our facility during that time. Ages ranged from 48 to 94 years, with 156 (72.2% of fractures; 0.39% of all individuals) of individuals meeting age-based screening criteria (aged ≥65 for women and ≥70 for men) at time of fracture. Nine individuals with hip fractures had greater than one discrete hip fracture, confirmed as separate by chart review.

From October 2013 to September 2019 there were 156 individuals admitted with a new hip fracture diagnosis, representing 0.37% of the averaged 46,327 individuals during that time. Ages ranged from 26 to 99 years. Of the hip fractures, 110 (70.5% of fractures) were in individuals meeting age-based screening criteria representing 0.24% of the averaged total individuals served and a 38.5% decrease (p<0.0001) in hip fracture admissions when compared to the prior six years. One individual had greater than one discrete hip fracture, representing an 88.9% lower rate (p<0.0001) of repeated fractures compared to the prior timeframe.

Men represented 355 (95.4%) of the 372 fractures seen from 2007 to 2019. CONCLUSION: A statistically significant decrease in hip fracture admission rates in women aged ≥65 and men ≥70 and in repeat hip fractures was observed in the 6 years since BHT inception compared to the 6 years prior.
MON-452 Poorly Differentiated Thyroid Carcinoma Metastatic to the Adrenal Gland
Authors: Mathias Priyanka , Manavalan Anjali , Aleksic Sandra , Bloomgarden Noah , Schubart Ulrich
Published: May 2020

Background: Poorly differentiated thyroid carcinoma (PDTC) constitutes 1-15% of all thyroid cancers.1 Invasive adrenal metastases secondary to PTDC are exceedingly rare.

Clinical Case: A 64-year-old woman with a non-toxic multinodular goiter presented with right upper quadrant abdominal pain and distension for three months. CT imaging revealed a 13.5 cm right suprarenal retroperitoneal mass invading the liver and inferior vena cava (IVC), concerning for adrenocortical carcinoma. She underwent resection of the mass with en block right adrenalectomy, partial hepatectomy, and IVC resection. Pathology demonstrated metastatic thyroid cancer with necrosis of the adrenal gland and IVC. Immunohistochemical staining was positive for PAX8, TTF1, and thyroglobulin (Tg). Completion thyroidectomy revealed an encapsulated 2 cm focus of PDTC with Hurthle cell phenotype in the right thyroid lobe. The mitotic activity was 5/10 per HPF. There were focal areas of tumor necrosis, 3 foci of capsular invasion, and extensive angioinvasion. Surgical margins were free of tumor invasion. Eight resected lymph nodes were negative for malignancy (Stage T1bN0M1; AJCC 8, Stage IVb). Genetic testing was positive for somatic mutations of NRAS, TERT, PTEN, and GNAS with broad copy number loss on chromosome 22q conferring aggressive tumor behavior.3

MRI of the brain and spine ruled out additional metastases. A radioactive iodine (RAI) whole-body scan (WBS) showed residual uptake of 7.6% in the right thyroid bed and a focus of increased uptake at the right sternoclavicular joint. A therapeutic dose of 206 mCi of I-131 was administered. A post-therapy WBS demonstrated focal activity in the right thyroid bed, distal right clavicle, and lower lung lobes. Chest CT and MRI of the right shoulder revealed no structural evidence of metastases corresponding to radiotracer uptake. The stimulated Tg level prior to RAI was 323 ng/mL with a TSH of 66 uU/mL (0.4-4.6 uU/mL). Tg antibodies were undetectable. She was maintained on 150 mcg of levothyroxine with the goal of TSH suppression. Tg levels declined to 4.8 ng/mL at three months, and to 0.3 ng/mL eight months post-RAI.

Discussion: PDTC is an aggressive thyroid cancer subtype with distant metastasis reported in 36-85% of cases.2 Distant metastasis is predictive of poorer outcomes, with patients three times more likely to die from the disease than those without metastatic disease.1 Adrenal metastasis of thyroid cancer is rare, and unlike in our patient, usually asymptomatic and frequently detected on a post-therapy scan. Despite a dramatic response to therapy, given the poorly differentiated features of the primary tumor, a whole-body PET-CT is warranted to evaluate for RAI refractory disease.

References:

1. Ibrahimpasic T et al. J Clin Endocrinol Metab. 2014;99(4):1245-52.

2. Sanders EM Jr et al. World J Surg. 2007;31(5):934-45.

3. Cheng DT et al. J Mol Diagn. 2015;17(3):251-64.
MON-260 Sinonasal Papilloma Masquerading as a Pituitary Macroadenoma
Authors: Cohen Melissa , Wilson John , Toft Daniel Joseph
Published: May 2020

Background: Sinonasal tumors are rare, with annual worldwide incidence of approximately 1 in 100,000, and are not commonly considered in the differential diagnosis of pituitary tumors (1). Sinonasal tumors are well known for their invasiveness, tendency to recur and association with malignancy. We present a case of sinonasal papilloma presenting as a large suprasellar mass.

Clinical Case: A 61 year-old male with a past medical history including type 2 diabetes mellitus presented with chief complaints of headaches and visual disturbances over the past 6 months. Prior to admission he experienced episodes of left eye midline deviation associated with diplopia. New onset dysphagia associated with leftward tongue deviation prompted him to seek medical attention. The social history was notable for chemical exposures in his work at a hair salon; he is sexually active with his husband. He has had no sexually transmitted infections and has been vaccinated against human papilloma virus (HPV). CT of the brain showed a large sellar mass.

A subsequent MRI of the pituitary demonstrated a large destructive mass centered on the clivus elevating the pituitary gland into the suprasellar cistern. The mass measured 6 cm x 4.5 cm in the axial plane with displacement without invasion of the cavernous sinuses. The mass extended anteriorly into the ethmoid sinuses and extended posteriorly into the prepontine cistern displacing the basilar artery.

Pituitary hormonal analysis included a 250 mcg Cosyntropin stimulation test resulting with a random cortisol of <1.0 ug/dl rising to 17.7 ug/dl following Cosyntropin administration. Additional anterior pituitary results included FSH of 3.8 mIU/ml (1.5-14 mIU/ml), LH of 1.3 mIU/ml (1.4-7.7 mIU/ml), total testosterone of 230 ng/dl (300-700 ng/dl), and prolactin 11.1 ng/ml (2.6-13 ng/ml).

Ophthalmology was consulted for visual field testing which proved normal, however a partial left cranial nerve VI palsy was noted likely secondary to cavernous sinus involvement. A biopsy of the sellar mass was obtained by bedside nasal endoscopy. The initial biopsy was consistent with a non-dysplastic, inverted sinonasal papilloma with negative HPV and P16 serologies. The patient underwent resection of the pituitary mass, with surgical pathology showing superficially invasive squamous cell carcinoma arising from sinonasal papilloma.

Conclusion: This is one of the very few cases reported in the literature of a sinonasal papilloma masquerading as a pituitary mass. Sinonasal papilloma should be considered when evaluating large destructive suprasellar tumors. Although a benign tumor, the local aggressiveness of sinonasal papilloma and the potential to give rise to squamous cell carcinoma highlights the significance of identifying this lesion.
SUN-391 Denosumab Treatment of Patients with Osteoporosis and Idiopathic Hypercalciuria
Authors: Chu Winston S , Chu James W
Published: May 2020

Background: Idiopathic hypercalciuria (IHC) is associated with reduced bone mineral density (BMD) and higher risk of osteoporotic fractures. Denosumab is a RANK-ligand inhibitor that prevents osteoporosis-related fractures. No previous published studies have specifically evaluated denosumab treatment of osteoporosis patients with IHC.

Methods: Retrospective chart review from a private endocrinology clinic identified 31 consecutive patients with osteoporosis (prior fragility fracture and/or t-score ≤-2.5 on bone density scan) with concomitant diagnosis of IHC (defined as urine calcium > 4.0 mg/kg weight/d when intaking low-moderate calcium amounts), who had received at least 3 denosumab injections. Comparisons were made for BMD measurements determined by dual-energy x-ray absorptiometry done before denosumab initiation, and after the latest dose.

Results: There were 28 women and 3 men, with average age of 71.9 ± 8.9 years. 20 subjects had prior total of 31 fragility fractures. Baseline 24-hr urine calcium was 331 ±65 mg/day. Average exposure to denosumab therapy was 9.0 ± 4.8 doses. 27 of these patients received concomitant thiazide diuretics during the course of their denosumab therapy. Baseline t-scores were -2.4 ± 0.8 at lumbar spine, -1.5 ± 0.7 at total hip and -1.8 ± 0.5 at femoral neck. After denosumab therapy, the t-scores were respectively -1.9 ± 0.9, -1.3 ± 0.8 and -1.6 ± 0.7. Mean increases in BMD were seen at the lumbar spine of 6.2 ± 8.4%, at the total hip of 3.2 ± 6.0%, and at the femoral neck of 2.5 ± 8.0%

19 patients were considered to have (+) BMD responses, based on consistent increases in BMD and/or t-scores across all spine and hip sites. 4 patients had (-) BMD responses, based on decreased BMD and/or t-scores across all sites. 6 patients had mixed responses and 2 did not have comparative BMD data. Baseline urine calcium did not seem to correlate with clinical responses. Those patients with longer duration of thiazide and/or denosumab use had higher likelihood of (+) BMD responses. However, during the course of follow-up, 4 subjects suffered 7 fragility fractures while treated with denosumab: 3 with (+) and 1 with (-) BMD responses.

Conclusion: Denosumab can effectively increase BMD in a cohort of osteoporosis patients with IHC, the majority of whom also received thiazide. However, increased BMD response did not necessarily predict lower risks of fragility fractures. Further research needs to evaluate the role of denosumab therapy in such high-risk patients.
SAT-745 Lower Serum Estradiol Levels in Assigned Female at Birth Transgender People with Initiation of Testosterone Therapy: Results from the European Network for the Investigation of Gender Incongruence (ENIGI)
Authors: Defreyne Justine , Aers Xavier-Philippe , Collet Sarah M , Wiepjes Chantal , Fisher Alessandra Daphne , Schreiner Thomas , Martin Den Heijer , T’Sjoen Guy G
Published: May 2020

Introduction: Aromatization of exogenous testosterone might result in increased estradiol levels. Concerns have been raised about undesired estrogenic effects in assigned female at birth (AFAB) transgender people. How serum estradiol levels change after initiation of testosterone therapy and if these levels should be monitored, remains unclear. Methods: This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Serum levels of sex steroids were assessed in 746 AFAB transgender people during a three-year follow-up period, starting at the initiation of hormone treatment. Results: Estradiol levels decreased from median [P25-P75] 45.5[24.0-102.2]pg/mL to 36.5[25.0-46.2]pg/mL over three years (P<0.001), a change was already noticeable during the first three months (mean - 17.1 pg/mL, 95% CI -23.8 - -10.6, P<0.001). Serum estradiol levels were lower in people without endogenous estradiol production (contraceptive users or post gonadectomy) at baseline and after three months, compared to people with endogenous estradiol production. Using long acting testosterone undecanoate injections resulted in a more prominent decrease in serum estradiol values over twelve months, compared to short acting mixed testosterone esters (P<0.001) or testosterone gel (P=0.001). Changes in serum estradiol were positively correlated to changes in LH (ρ = 0.107, P<0.001) and negatively correlated to changes in FSH levels (ρ=-0.167, P<0.001) and body mass index (ρ=-0.082, P<0.001). Conclusion: Testosterone administration in AFAB transgender people results in decreasing serum estradiol levels. Although an underlying mechanism for the observed decrease in serum estradiol levels remains difficult to fathom, our results suggest that testosterone administration suppresses endogenous estradiol production. The exception found in people without endogenous estradiol production may be attributed to aromatization of exogenous testosterone.
MON-383 A Study on the Oral Vitamin D Supplementary Treatment of Korean Children and Adolescents
Authors: Yang Seung
Published: May 2020

Purpose: Between 2017 and 2018, the prevalence rate of vitamin D deficiency (VDD) among children and adolescents in Korea (single institution) was 68.4 percent (59.6 percent for males and 72.5 percent for females). However, effective vitamin D supplements are not consistent in literature. We tried to find out about the dosage and the duration of the administration. Methods: The study was conducted on 2,770 children aged 0-18 who tested serum vitamin D concentrations for outpatients and inpatients at our hospitals from August 2017 to July 2019. One group was treated with maintenance doses and the other group was treated with maintenance doses after oral vitamin D 2000 IU/d for six weeks. The maintenance dose was 400 IU/d before puberty and 1000 IU/d after puberty. Results: There was a significant correlation between serum 25(OH) vitamin D concentration and gender, age, season, weight SDS and BMI SDS (p=0.000, p=0.000, p=0.000, p=0.000, p=0.002, respectively). After 6 months of oral Vitamin D treatment, serum 25 (OH) Vitamin D concentration was increased in both groups (p=0.000, p=0.000, respectively). In a group treated with maintenance doses after oral vitamin D 2000 IU/d for six weeks, it was found a higher rate of change to vitamin D sufficiency (p=0.000). Conclusions: The prevalence rate of VDD increases in female, older age, overweight and winter. The serum 25 (OH) vitamin D concentration increased in both groups after 6 months of treatment. In VDD children, It seemed appropriate to take an oral Vitamin D 2000 IU/day for 6 weeks before maintenance treatment according to the current guideline treatment.
SUN-055 Prenatal Exposure to Artificial Sweeteners
Authors: Halasa Brianna C , Sylvetsky Allison , Conway Ellen M , Walter Peter J , Cai Hongyi , Walter Mary F , Schouppe Eileen , Hui Lisa , Rother Kristina I
Published: May 2020

Introduction: In adults, epidemiologic studies consistently show negative health outcomes (e.g. insulin resistance, stroke) related to artificial (or non-nutritive) sweetener (NNS) intake. In children, NNS sweetened beverage consumption is associated with higher total energy and sugar intake. In infants, we documented the immediate appearance of NNS in breast milk after mothers consume diet soda. A positive association between prenatal NNS exposure and higher BMI at 1 year of life has been observed in infants whose mothers routinely consumed NNS during pregnancy. In mice, we recently reported marked changes in intestinal microbiome and hepatic detoxification pathways of pups that had been exposed to NNS via their mothers’ intake during pregnancy and lactation. Thus, we conducted a pilot project to determine whether there is direct evidence for prenatal NNS exposure in humans. In future studies, we will investigate effects on health outcomes.

Methods: Concentrations of 3 NNS (acesulfame-potassium (ace-K), sucralose and saccharin) were measured with liquid chromatography-mass spectrometry in cord blood samples (n=15) and amniotic fluid samples (n=13). Aspartame cannot be measured because of its prompt metabolism into aspartic acid and phenylalanine. The cord blood samples were obtained from offspring of women enrolled in a sickle cell clinical trial at the NIH, while the amniotic fluid samples had been obtained for clinical purposes during the 3rd trimester. No dietary information was available other than 2 of 13 women were not in the fasting state when undergoing amniocentesis.

Results: In the cord blood samples, ace-K and saccharin were present in 12/15 (80%) samples. None of the samples contained sucralose. In the 13 amniotic fluid samples, 10 (77%) samples contained at least one sweetener. One sample was positive for all 3 sweeteners. Maximum concentrations in cord blood were 6.5 ng/mL for ace-K and 2.7 ng/mL for saccharin, while maximum concentrations in amniotic fluid were 78.9 ng/mL for ace-K, 55.9 ng/mL for saccharin, and 30.6 ng/mL for sucralose (non-fasting sample). Most women were in the fasting state before undergoing amniocentesis or giving birth, thus NNS peak concentrations could not be determined in this pilot study.

Discussion and Conclusion: 80% of cord blood samples (babies’ blood) and 77% of amniotic fluid samples (reflecting babies’ direct gastrointestinal/lung exposure) contained ace-K, saccharin and/or sucralose. We speculate that NNS exposure may influence in utero growth and development, e.g. sweet taste preference and metabolic pathways. Prospective studies are necessary to test these hypotheses. Results will determine whether current recommendations (or lack thereof) regarding NNS intake during pregnancy and lactation need to be revised.
MON-591 Effect of Liraglutide Treatment on Proglucagon-Derived Peptides
Authors: Kim Sun , Abbasi Fahim , Nachmanoff Clara , Kumar Ajay , Kalra Bhanu , Savjani Gopal , Mantzoros Christos
Published: May 2020

Liraglutide is a glucagon-like peptide 1 receptor agonist (GLP-1ra) and has 97% homology to native GLP-1. Native GLP-1 derives from proglucagon, which is also a prohormone for other peptides including GLP-2, glucagon, oxytomodulin, glicentin, and major proglucagon fragment. Aside from GLP-1 and glucagon, the actions and roles of the other proglucagon-derived peptides remain unclear. In addition, the effect of liraglutide treatment on these peptides are unknown. The aim of this study was to evaluate the effect of treatment with liraglutide compared with placebo on proglucagon-derived peptides. Adults who were overweight/obese (BMI 27-40 kg/m2) with prediabetes were randomized to liraglutide 1.8mg daily vs placebo for 14 weeks. All participants met regularly with a registered dietitian and were advised to decrease calorie intake by 500 kcal/day. Proglucagon-derived peptides were measured during mixed-meal tolerance test (MMTT) at baseline and after 14 weeks in a subset of individuals with saved samples (n=16 on liraglutide, n=19 on placebo). The MMTT involved eating breakfast at 08:00 (20% of daily energy intake) and lunch at 12:00 (40% of daily energy intake). Blood was collected before breakfast and hourly from 08:00 to 16:00. The area-under-the curve (AUC) was calculated for all proglucagon-derived peptides using the trapezoidal method. Individuals treated with liraglutide lost twice as much weight as those assigned to placebo injections (mean ± SD, 6.1 ± 1.9 vs 3.2 ± 2.2 kg, p<0.002). Treatment with liraglutide also was associated with a significant (p < 0.01) decrease in all proglucagon-derived peptides. In the placebo group, only glucagon AUC significantly decreased after 14-weeks (P=0.002). Our study demonstrates for the first time that liraglutide treatment is associated with decrease in proglucagon-derived peptides, suggesting downregulation of endogenous proglucagon. The effects of this downregulation are unknown and need further study.
MON-505 Quantitative Characteristics and Sonographic Patterns Before and After Thyroid Radiofrequency Ablation
Authors: Wu Ming-Hsun
Published: May 2020

Although most thyroid nodules (TNs) are benign and require only serial observation, some may need treatment for symptoms. Radiofrequency ablation (RFA) has been used and shown to be a promising and well-tolerated new approach. The efficacy of RFA is evaluated by using parameters such as volume reduction ratio (VRR), and cosmetic or symptomatic improvement. However, no index is now available to predict the therapeutic success before RFA. And apart from size reduction, little is known about their ultrasonography (US) appearances after RFA. The purpose of this study was to 1) assess the effectiveness of single session RFA treatment on volume reduction 2) determine if quantitative US characteristics are correlated to the VRR 3) demonstrate the US characteristics from the baseline and during the follow-up. Quantification of characteristics was performed using commercial software. The CAD software classified nodules into the 2015 ATA sonographic patterns and TIRADS categories. All patients underwent a single treatment session and with significant improvement in cosmetic and pressure symptoms. It shows that there is a direct correlation between the initial tumor size/cyst component percentage and VRR. The US characteristics are significant different after RFA, and the tumors were categorized to more suspicious ATA patterns and had higher TIRAD scores. In conclusion, RFA is effective on volume reduction and US characteristics correlated with therapeutic success. Post RFA US features may potentially mislead and clinicians should always keep in mind.
SUN-510 Prolonged RAIA Induced Thyroiditis After 131 I Therapy for Graves’ Hyperthyroidism
Authors: Aljaberi Asma Khaled , Boharoon Hessa
Published: May 2020

Radioactive iodine ablation (RAI) has been used for the treatment of Graves’ hyperthyroidism since 1946 and it is the primary recommended modality for Graves’ disease treatment in many countries. Acute painful radiation thyroiditis after radioiodine treatment for hyperthyroidism of Graves’ disease is considered uncommon. The prevalence is 1-5% in patients treated with 131I therapy for hyperthyroidism. Dose of RAI and thyroid volume can be precipitating factors for post radiation thyroiditis. The higher RAI dose increases the chance of RAI thyroiditis while the larger goiter size decreases the absorbed radiation dose in the thyroid gland. We present a 25-year-old Emirati male previously healthy, who was referred to our service for hyperthyroidism management. He presented with thyrotoxicosis in absence of goiter. All investigations revealed that graves’ disease is the primary cause of his hyperthyroidism. He was treated with RAI ablation 18.3 mCi. Day four after RAI, he presented with severe pain in the anterior neck associated with fatigue, tremor, palpitation and weight loss. Symptoms lasted for 6 weeks post RAI. There was laboratory evidence of thyrotoxicosis presented with further suppression of TSH and higher fT4 than the baseline. Acute radiation thyroiditis was diagnosed and has been commenced on propranolol 10mg BID. Symptoms completely resolved after 6 weeks of treatment and thyroid function returned to normal level. The patient has remained asymptomatic on continued follow up care till eventually became hypothyroid clinically and biochemically. Our case reflects that radioiodine thyroiditis can last for longer period and occur after larger doses of 131I treatment in absence of goiter. Our patient has RAIA induced thyroiditis lasted for 6 weeks post 18.3mCi of 131I, and has no goiter, which were both contributing factors for RAIA induced thyroiditis
SAT-676 Pembrolizumab Induced Worsening Glycemic Control and DKA in Type 2 Diabetes Mellitus
Authors: Goud Sarita , Thar Yu Yu
Published: May 2020

INTRODUCTION Pembrolizumab(Keytruda) is a humanized IgG4 anti-programmed cell death-1 (PD-1) antibody serving as an immune-checkpoint inhibitor, now approved by FDA to treat several types of cancer.

Although there are few reported cases of pembrolizumab induced new onset DKA in a non diabetic patients due to its autoimmune nature, its association in worsening glycemic control and DKA in pre-existing type 2 Diabetes mellitus is not well established.

CASE 79 years old female with past medical hx of DM type 2 (Hba1c 7.4 was started on metformin), COPD(on chronic steroids and trilogy machine at home), recently diagnosed with poorly differentiated adenocarcinoma of the left lung, metastasis to liver, PDL 1 positive at 99%, started on palliative chemotherapy with Keytruda, 2 weeks after the third cycle of keytruda presented to the ED for AMS. Patient noted to be very dehydrated, somnolescent and tachypnea. Labs consistent with sugars > 600, potassium 6.8, Bicarb 5, Anion gap 33, beta hydroxybutyrate 11.5 (on 7/15/19 0.6), HbA1c 9.7,(On 12/15/16 7.3, 9/25/18 6.7, 1/22/19 7.4). PH 7.31, lactate 2.4. WBC count 21.5- no infectious source identified (CXR, CT brain, UA clean). Patient was admitted for DKA and treated with IV insulin and IV fluids. After medically stable patient was discharged with Insulin regimen. Within 5 days after being discharged, patient presented to ED again with DKA with PH 7.27, Bicarb 8, anion gap 22, sugars>600, beta hydroxybuterate 13.70. Patient was Rx for DKA- after a week of hospitalization was discharged to Hospice(due to metastatic cancer) and few weeks later expired.To summarize, pt with well controlled type 2 DM on metformin presented with frequent DKA 2 weeks after treatment with third cycle of keytruda leading to worsening glycemic control in-turn making patient Insulin dependent.

CONCLUSION Incidence of Type 1 DM with pembrolizumab treatment is being increasingly recognized and reported, and DKA is a common initial presentation. However we need further studies to establish the mechanism of worsening glycemic control leading to Insulin dependent and DKA in patients with pre-existing type 2 diabetes.

Also, physicians should counsel patients about this potential immune related adverse effect and educate them about the symptoms of hyperglycemia and DKA.

REFERENCES Immune checkpoint inhibitors and type 1 diabetes mellitus: a case report and systematic review Jeroen M K de Filette1, Joeri J Pen2, Lore Decoster3, Thomas Vissers4, Bert Bravenboer1, Bart J Van der Auwera5, Frans K Gorus5, Bart O Roep6,7, Sandrine Aspeslagh3, Bart Neyns3, Brigitte Velkeniers1 and Aan V Kharagjitsingh1,2,5,8

Immune checkpoint inhibitors: an emerging cause of insulin-dependent diabetes. Anupam Kotwal1, Candace Haddox2, Matthew Block3, Yogish C Kudva1. BMJ open Diabetes and research, Vol 7, issue1.
OR07-03 Continuous Subcutaneous Delivery of RhPTH(1-84) by Pump in Adults with Hypoparathyroidism
Authors: Bove-Fenderson Erin , Wong Daniel , Cusano Natalie Elissa , Mannstadt Michael
Published: May 2020

More than 80,000 people in the United States have hypoparathyroidism, a disease of low or absent parathyroid hormone (PTH) leading to hypocalcemia and hyperphosphatemia. Conventional treatment with oral calcium and active vitamin D increases serum calcium concentrations but does not replace the physiologic functions of PTH. Once-daily subcutaneous injections of recombinant human (rh) PTH(1-84) were recently approved for the treatment of hypoparathyroidism, but are not consistent in correcting biochemical abnormalities and alleviating symptoms for all patients. In cases in which single or multiple daily injections of rhPTH(1-84) are insufficient for controlling symptoms, continuous subcutaneous infusion via insulin pump is used as a therapeutic alternative. Pump therapy with PTH(1-34) has some support in the literature as an effective form of treatment for hypoparathyroidism.1However, the effects of pump therapy with rhPTH(1-84) in patients with hypoparathyroidism have not been reported. Five women with chronic postsurgical hypoparathyroidism who received treatment at three different endocrine outpatient clinics in the United States were transitioned from multiple daily injections of rhPTH(1-84) to continuous delivery of rhPTH(1-84) using the Omnipod insulin pump. The patients’ ages ranged from 27 to 60 years old and all had had hypoparathyroidism for at least 5 years. All of the patients were transitioned from conventional therapy with oral calcium and calcitriol to subcutaneous injections of rhPTH(1-84), and then switched to continuous subcutaneous administration using an insulin pump. In all five patients, increased serum calcium concentrations and decreased serum phosphate concentrations were observed with increased frequency of PTH administration. Serum calcium concentrations were within the normal to high-normal range and serum phosphate concentrations were in the normal range on pump therapy. Urinary calcium was well-controlled (<250 mg/day) in four of the five patients. All of the women reported a decrease in symptoms while receiving pump-administered rhPTH(1-84), including a lower incidence of fatigue, brain fog, tingling, and muscle cramps compared to standard therapy and daily injections. This is the first report of patients with hypoparathyroidism on long-term therapy with continuously infused subcutaneous rhPTH(1-84) using a pump. Pump therapy improved key parameters of mineral metabolism; normalizing serum calcium in all patients and urinary calcium in four out of five patients. Clinical trials with larger cohorts are needed to confirm the efficacy of this promising mode of administration of rhPTH(1-84). Reference: 1. Winer KK. Advances in the treatment of hypoparathyroidism with PTH 1-34. Bone. 2019;120:535-541.
SUN-174 Giant Bilateral Myelolipomas in a Patient with Congenital Adrenal Hyperplasia
Authors: Duro Teodor , Palinka Bethany , Gomez Nephtali , Codorniz Kevin Anthony
Published: May 2020

INTRODUCTION Adrenal myelolipomas are rare, benign adrenal tumors composed of adipose and hematopoietic tissue. The first mass was identified by Gierke in 1905 and named by Oberling in 1929. Myelolipomas often coexist with CAH and other hormonal disorders although this relationship is still unclear. We present a rare case of giant bilateral myelolipomas in a patient with CAH. CASE REPORT A 28-year-old female with a history of CAH due to 21-hydroxylase deficiency diagnosed at birth presented to our endocrinology clinic after being lost to follow up for 4 years and a history of poor follow up for several years before that. She reported being on varying doses of hydrocortisone throughout her life with the most recent being 10mg TID with poor adherence. Over the past 4 years, the patient noticed increased hair growth on her face, abdomen, inner thighs and back, abdominal striae, and weight gain of 80-100lbs. She also reported a history of bilateral flank pain for the last several years, requiring several ER visits where she was told she had adrenal nodules based on scans that were done. A few months prior to her first visit to our clinic she developed increasing flank pain, which prompted a visit to a local ER. A CT of the abdomen revealed bilateral adrenal septated complex cystic masses measuring 19x12x20 cm on the left and 12x11x11 cm on the right. Initial biochemical workup was consistent with poorly managed CAH: ACTH 45.2 pg/mL (n 7.2 - 63.3), total testosterone 401 ng/dl (n 8-48), androstenedione 2085 ng/dl (n 41-262), 17-OH progesterone 18880 ng/dl, (n 15-290), DHEA-sulfate 423.5 ug/dl, (n 84.8-378), and estradiol 72.0 pg/dl, (n 12.5-498). Plasma renin activity was 13.904 ng/mL/hr (n 0.167-5.380 ng/mL/hr). Based on laboratory results hydrocortisone was decreased to 10mg BID and dexamethasone was added. Due to severe recurrent pain the patient underwent bilateral adrenalectomy. On pathology the bilateral masses were found to be myelolipomas with the left diameter measuring 22.3 cm and the right measuring 16.5 cm. Post-operatively her lab values showed significant improvement compared to her initial workup: ACTH 4.1 pg/mL, total testosterone 6.7 ng/dl, androstenedione 73 ng/dl, 17-OH progesterone 29 ng/dl, DHEA sulfate 7.2 ug/dl, and estradiol 228.3 pg/dl. Plasma renin was also within normal range at 1.776 ng/mL/hr. On follow up, the patient had recovered well and reported improvement in her flank pain. CONCLUSION This is a rare case of giant bilateral adrenal myelolipomas. Despite these tumors being benign and often asymptomatic, they are clinically relevant due to their role in the differential diagnosis of an adrenal mass. The presence of megakaryocytes in a biopsy specimen of a fatty adrenal mass is pathognomonic for myelolipoma. Treatment is guided by the tumor size and patient presentation; masses >7 cm, hormonally active, or causing abdominal pain should be surgically removed as demonstrated in this case
MON-243 Atypical Presentation of Isolated Adrenocorticotropic Hormone Deficiency and Sheehan’s Syndrome
Authors: Lugo López Zahira Marie , Santana Nadyeschka Angelique Rivera , Diez Andrea del Toro , Garcia Michelle Marie Mangual , Sanchez Ernesto Sola , Gonzalez Bossolo Alex N
Published: May 2020

Introduction: Isolated adrenocorticotropic hormone (ACTH) deficiency is a rare pituitary hormone deficiency defined by secondary adrenal insufficiency and normal secretion of all other pituitary hormones. Patients present with fatigue, weakness, weight loss, anorexia, nausea, low cortisol levels and low ACTH levels. Isolated ACTH deficiency is more common in males and usually presents in the fifth decade of life. Main mechanisms involved in the pathogenesis are genetics and autoimmune causes, traumatic brain injury and infarction of the pituitary postpartum, known as Sheehan’s syndrome. Sheehan’s syndrome is characterized by postpartum hemorrhage, failure to lactate and menstrual irregularities and it can occur from immediate postpartum period to years after delivery. The most common hormone deficiencies are prolactin and growth hormone. Empty sella is the most common finding on brain MRI. We are reporting a case of a woman in her third decade with isolated ACTH deficiency due to Sheehan’s syndrome two years postpartum, able to lactate, with normal menses and normal brain MRI. Clinical Case: A 33-year-old woman G3P3A0 with hypothyroidism who was referred to Endocrinology clinics due to tiredness, fatigue and weakness. She reported postpartum hemorrhage requiring 4 PRBC transfusions and IV steroids after last pregnancy 5 years ago. Patient was able to lactate after pregnancy and continued in her usual state of health until 3 years ago when she referred loss of consciousness with traumatic head injury due to hypoglycemia. At Endocrinology office physical examination and vital signs were unremarkable, including no blood pressure or heart rate variations with positional changes. Despite hypothyroidism being adequately controlled, she continued with extreme fatigue and weakness affecting her quality of life, for which cortisol and ACTH levels were ordered. Laboratories showed normal electrolytes, negative autoantibodies, cortisol 0.20 μg/dL (5-25 μg/dL) and ACTH 22 pg/mL (10-60 pg/mL) suggesting partial isolated ACTH deficiency. ACTH stimulation test was done and noted with suboptimal response. Evaluation of other anterior pituitary hormones was normal. Brain MRI showed normal pituitary gland. She was started on hydrocortisone in AM and PM and symptoms resolved. Conclusion: Immediate recognition of isolated ACTH deficiency due to Sheehan’s syndrome is necessary due to the availability of effective treatment and morbidity and mortality associated with this serious condition. To our knowledge isolated ACTH deficiency due to Sheehan’s syndrome in which the patient was able to lactate and normal findings on brain MRI has not previously been reported.References: Shivaprasad C. Sheehan’s Syndrome: Newer advances. Indian J Endocrinol Metab. 2011 Sep; 15(3): S203-207. DOI:10.4103/2230-8210.84869.
SUN-580 PCSK9 and Lp(a): Association Between PCSK9 Level and Larger Apo(a) Isoform Size in African-Americans and Caucasians
Authors: Byambaa Enkhmaa , Kim Kyoungmi , Zhang Wei , Truax Kevin , Erdembileg Anuurad , Berglund Lars Folke
Published: May 2020

Introduction: An elevated level of lipoprotein(a) [Lp(a)] is an independent causal risk factor for cardiovascular disease. Non-genetic factors do not appreciably influence Lp(a) levels due to a strong genetic control. However, inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) has been shown to reduce Lp(a) levels. The association of PCSK9 with Lp(a) level and its major genetic determinant—apolipoprotein(a) [apo(a)] size—is not fully understood. In this study, we assessed the relationship between PCSK9, Lp(a) level, apo(a) size, age, and race/ethnicity.

Methods: Healthy Caucasian and African-American families were recruited from the general population (age range: 6–74 years, N=267). PCSK9 and Lp(a) levels were assayed enzymatically; apo(a) isoform and LPA allele sizes and isoform-specific Lp(a) levels were determined.

Results: In all participants, PCSK9 levels differed significantly by race/ethnicity, age, and sex. Thus, the mean PCSK9 levels were significantly higher in African-Americans vs. Caucasians (104 ± 29 vs. 95 ± 30 ng/mL, respectively, p=0.020), in adults vs. children (102 ± 29 vs. 92 ± 31 ng/mL, respectively, p=0.001) and in females vs. males (103 ± 30 vs. 94 ± 29 ng/mL, respectively, p=0.007). PCSK9 levels were not associated with total plasma Lp(a) levels neither in all participants nor in ethnicity-specific analyses. However, PCSK9 levels were significantly and positively associated with isoform-specific Lp(a) levels carried by the larger apo(a) size in all subjects (r=0.139, p=0.0361). In race/ethnicity analyses, a significant association was seen for African-Americans (r=0.268, p=0.0199), but not for Caucasians. In contrast, there were no significant associations of PCSK9 with isoform-specific Lp(a) levels for the smaller apo(a) sizes in all participants nor in ethnic-specific analyses. Of note, PCSK9 levels were significantly negatively associated with the larger apo(a) isoform sizes in all participants (r=-0.139, p=0.0366). Although significant in both groups, heritability of PCSK9 level was higher in Caucasians than in African-Americans (47% vs. 22%, respectively).

Conclusions: Among African-Americans, but not Caucasians, PCSK9 levels were associated with isoform-specific Lp(a) levels carried on larger, but not smaller, apo(a) sizes. The findings illustrate a diverging relationship of PCSK9 with isoform-specific Lp(a) levels.
SAT-607 The Vagus Nerve and the Hypothalamus Mediate Different Aspects of the Anorectic Effects of PYY3-36
Authors: Alonso Aldara Martin , Cork Simon C , Ma Yue , Arnold Myrtha , Herzog Herbert , Bloom Stephen R , Distaso Walter , Murphy Kevin Graeme , Salem Victoria
Published: May 2020

Background: Drugs that safely promote weight loss are required to treat the obesity crisis. The gut hormone peptide YY 3-36 (PYY3-36) is secreted post-prandially to suppress appetite via the Y2 receptor (Y2R). However, it is unclear whether PYY3-36 acts directly on the Y2R in the hypothalamic arcuate nucleus (ARC) or the afferent vagus nerve to inhibit food intake. Understanding the pathways by which PYY3-36 mediates its anorectic effects may facilitate the therapeutic targeting of this system.

Methods: Y2R knockdown in the ARC (ARC-Y2R-KD) was achieved by stereotactic injection of Cre-expressing adeno-associated virus (AAV-Cre) in Y2R-flox C57Bl/6 mice. Y2R KD in the vagus was achieved by bilateral microinjection of AAV-Cre into the nodose ganglia (NG), where the cell bodies of vagal afferents reside. An alternative germline model of sensory nerve Y2R knockdown was generated using Nav1.8-Cre mice crossed with the Y2R-flox strain (Nav1.8-Y2R-KD). Feeding behaviour over 10 days in metabolic cages and the effects of endogenously released (after oral gavage of a nutrient bolus) or exogenously-administered PYY3-36 were investigated.

Results: NG-Y2R-KD animals had 60% reduction in NG Y2R mRNA but remained responsive to cholecystokinin, a positive control of vagal functionality. This is the first example of receptor specific adult vagal deafferentation in mice. The Nav1.8-Y2R-KD model achieved 30% receptor KD. Feeding patterns in the ARC-Y2R-KD and NG-Y2R-KD groups were highly different from their controls, with smaller, faster meals in the KD groups. The anorectic effects (at the next meal) of endogenous PYY3-36 were attenuated in NG-Y2R-KD. Low dose exogenous PYY3-36 at 5 µg/kg significantly reduced 2h post injection food intake (FI) in the control groups (n=8; P=0.045) but this was abrogated in the NG-Y2R-KD group. This pattern was mirrored in the Nav1.8-Y2R-KD model: low dose PYY3-36 significantly reduced FI 1h post-IP compared to vehicle in controls (-0.19±0.05 g; P =0.036; n=8) but not in the Nav1.8-Y2R-KD (-0.004±0.111 g; n=3). Peripherally-administered PYY3-36 at a high dose (30 µg/kg) decreased FI in all groups, including ARC-Y2R-KD.

Summary: These results suggest that endogenous PYY3-36 modulates meal patterning. The vagus nerve mediates physiological PYY3-36 signalling but alternative pathways, not exclusively via the ARC, may be more important in mediating its pharmacological effects. This is relevant for the design of more effective weight loss agents.