bluuebunny/crossref_metadata_2025 huggingface dataset:
MON-652 The Prevalence and Clinical Characteristics of Adult Patients Presenting with Sodium-Glucose Co-Transporter-2 Inhibitor Associated Euglycemic Diabetic Ketoacidosis
Authors: Clark Alexa , Mohammed Arifuddin Saad , Raut Amol , Moore Sarah , Awad Sara
Published: May 2020

Background: Sodium-Glucose Co-Transporter-2 Inhibitors (SGLT-2i) have been associated with euglycemic diabetic ketoacidosis (EuDKA). The pathophysiology is related to decrease insulin secretion given glucosuria and lower insulin to glucagon ratio, resulting in enhanced lipolysis and ketogenesis at a lower glucose level. SGLT-2i may unmask underlying undiagnosed type-1 diabetes/Latent Autoimmune Diabetes of the Adult (LADA).

Objective: (1)To describe the frequency and clinical characteristics of SGLT-2i associated EuDKA at a Canadian tertiary care centre. (2)To identify the most common underlying diabetes-type associated with EuDKA.

Methods: A chart review identified patients with SGLT-2i-associated EuDKA from June 2015 to May 2019 who presented to a Canadian tertiary care centre. Clinical characteristics include age, gender, diabetes type, SGLT-2i drug prescribed, laboratory results at the time of EuDKA and possible precipitants were reviewed. Pancreatic autoantibodies (anti-GAD-65, anti-islet cell, IA-2, and insulin antibodies) were measured to screen for the possibility of undiagnosed LADA.

Results: Between June 2015 to May 2019, there were 647 DKA events of which 43 were related to SGLT-2i (Prevalence 6.64%). Canagliflozin was the most common SGLT-2i (53.5%) followed by Empagliflozin (34.9%). The most common precipitant was infection (16.3%), followed by surgery (14%). At presentation, average blood glucose was 14.95±12.51 mmol/L, pH 7.23±0.16, HCO3 12.86 ± 5.51 mmol/L, potassium 4.40±0.86 mmol/L and anion-gap 22.05±5.51 mmol/L. Average HbA1c was 9.2%±2.10 and BMI was 29.34±4.49. Twenty patients had pancreatic autoantibodies testing and seven were positive (35%), most commonly anti-GAD-65 (71.4%). As a result, seven patients were diagnosed with LADA who were previously diagnosed with type-2 diabetes. Out of the 7 patients with LADA, 2 had a positive family history of type-1 diabetes.

Conclusion: SGLT-2i associated EuDKA could unmask underlying LADA. Further studies are warranted to determine if routine pancreatic antibodies should be drawn for diabetes typing prior to prescribing or at presentation of SGLT-2i associated EuDKA.
SAT-249 Polyarticular Osteoarthritis: A Disabling Manifestation of Acromegaly
Authors: Khan Azkia , Ejaz Hashim , Sekar Vijaykumar , Syed Sofia
Published: May 2020

Background

Acromegaly is a slow-onset rare endocrinopathy that is characterized by chronic overproduction of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Excess GH and IGF-1 levels lead to insulin resistance, which is implicated in most of the complications associated with acromegaly. We present a case of acromegaly, wherein the patient presented with worsening polyarthralgia and decreasing mobility. As the patient was undergoing workup for rapidly progressing osteoarthritis, the internist became suspicious of patient’s changing physical appearance.

Case

A 53-year-old man with medical history of diabetes mellitus and hypertension was referred to endocrine clinic on account of high IGF-1 levels, 909 ng/ml (normal: 37-245 ng/ml). He was seeking medical attention because of rapidly progressing polyarthralgia and stiffness for the last two years. His symptoms were intensifying despite use of non-steroidal anti-inflammatory drugs and intra-articular steroid injections. Imaging revealed severe degenerative changes and narrowing of joint space in bilateral hip, knee and glenohumeral joints. Internist observed that the patient was exhibiting stigmata of acromegaly such as enlargement of hands and feet, prognathism and dental space widening. Patient reported headaches, blurry vision, sleep apnea, dysphagia and right ear exostosis. Colonoscopy revealed hyperplastic polyps.

Repeat IGF- 1 levels were 910 ng/ml (Normal: 37-245 ng/ml). Oral glucose tolerance test showed failure of suppression of GH. Serial GH levels were 4.50, 5.08, 6.74, 5.81 and 5.21 ng/ml (Normal: 0.01- 0.97 ng/ml).

Tests for other endocrinopathies revealed the following results: serum prolactin 4 ng/ml (Normal <18 ng/ml), serum cortisol 7.9 ug/dl (Normal: 6-27 ug/dl), 24 hour urine cortisol 23mcg/24 hours (Normal: 3.5-45 mcg/24 hours), serum TSH 2.25 uIU/ml (Normal: 0.34- 3 uIU/ml), serum T4 level 0.7 ng/dl (Normal: 0.6-1.6 ng/dl) and serum T3 level 144.9ng/dl (Normal: 87-178 ng/dl). Serum total and free testosterone levels were 111 ng/dl (Normal: 240-950 ng/dl) and 3.89 ng/dl (Normal: 4.06-15.6 ng/dl) respectively and were suggestive of hypogonadism.

MRI Brain showed 12x10x8mm pituitary adenoma. He was referred for transsphenoidal surgery for resection of pituitary adenoma.

Conclusion

Polyarticular osteoarthritis is an early manifestation of acromegaly. Systemic diseases associated with acromegaly are the primary reason for which most patients seek medical attention. It is important to look for coexisting endocrinopathies whenever the diagnosis of acromegaly is established, since mass effect of pituitary adenoma can wreak havoc on the endocrine system of the body. High index of suspicion, early diagnosis and prompt treatment are the key to reverse some but not all comorbid conditions associated with acromegaly.
MON-699 Artifactual Hypoglycemia in a Patient with Prolonged Hospital Stay for Neuroleptic Malignant Syndrome
Authors: Swami Janya
Published: May 2020

Background: Hypoglycemia is rare in patients without diabetes. A low capillary glucose concentration is not sufficient to make a diagnosis of a hypoglycemic disorder. In fact, this has multiple sources of error. Fulfillment of Whipple’s triad is an essential step for establishing the diagnosis of a hypoglycemic disorder. Clinical case: A 47-year old Caucasian male with past medical history of paranoid schizophrenia was admitted to the ICU from an outside facility with catatonia and apneic spells following an acute change in mental status. He was diagnosed with neuroleptic malignant syndrome and Endocrinology was consulted after 137 days in the hospital for concerns of severe and recurrent hypoglycemia. The patient was non-verbal on evaluation and despite multiple capillary blood glucose readings of <70 mg/dL, including measurements as low as 29 mg/dL, he remained asymptomatic with absence of any clinical signs of an adrenergic response to hypoglycemic episodes. He was on continuous tube feeding through a PEG tube. The low capillary blood glucose measurements prompted rapid management with intravenous or oral dextrose based on the hypoglycemia protocol designed by the hospital. As a last resort, the patient was placed on a continuous dextrose infusion in addition to tube feeding to prevent hypoglycemia.Diagnostic evaluation: Following consultation, we ordered for a corresponding plasma glucose measurement to be done with any capillary blood glucose measurement of < 55 mg/dL prior to correction for hypoglycemia. For a capillary blood glucose measured at 48 mg/dL, corresponding plasma glucose was 95 mg/dL. Whipple’s triad was not fulfilled and no additional work up was pursued. We recommended calibration of the glucose monitors for the hospital unit where the patient was admitted with recommendations to stop monitoring capillary blood glucose in this patient in the absence of diabetes, signs/symptoms of hypoglycemia, medications implicated to cause hypoglycemia and ongoing nutrition with tube feeding. Follow-up: The patient remains in the hospital and is waiting placement at an extended care facility. Plasma blood glucose measurements remain within normal range.Clinical lesson: Artifactual hypoglycemia, though uncommon, is an important consideration when evaluating and managing hypoglycemia. Whipple’s triad is essential to make a diagnosis of true hypoglycemia. Several factors; patient, operator and machine-related, can impact measurements of capillary blood glucose measurements and often result in unnecessary treatment measures often causing inefficient and often preventable wastage of hospital resources and sometimes even harm the patient.
MON-435 Hashimoto Thyroiditis and Goiter: Never Cease Follow-Up
Authors: Sekar Vijaykumar , Ejaz Hashim , Khan Azkia , Syed Sofia Junaid
Published: May 2020

Background

Hashimoto thyroiditis (HT) is the most common cause of hypothyroidism in iodine-sufficient areas. Its incidence is estimated to be 3.5 per 1000 per year in women and 0.8 per 1000 per year in men (3). Primary thyroid lymphoma (PTL) is a rare complication of HT, but often forgotten. Regular follow-up and high clinical suspicion is needed to diagnose this complication early. We present a patient who developed PTL as a complication of HT after 10 years of diagnosis of HT and goiter.

Clinical case

A 70-year-old male with history of hypertension and obstructive sleep apnea followed up in the endocrine clinic for the last 10 years for Hashimoto thyroiditis and stable goiter presented with a sudden enlargement of right neck mass. In 2008 he was incidentally diagnosed with HT. In 2010 the patient returned with a neck swelling and further investigation revealed a cold nodule in the right lobe. The patient underwent aspiration biopsy with repeat finding of HT, and was followed up yearly with thyroid ultrasound and TSH. In 2014 due to concern in the echotexture of thyroid on ultrasound, he had a biopsy of the right thyroid nodule with findings again consistent with HT. No significant changes were noted on yearly follow-up ultrasound until March 2019. He presented 5 months later with a large mass on the right side of his neck. Ultrasound showed enlarged and confluent lymph nodes anterior to the enlarged right thyroid gland. Further CT evaluation showed a large right neck mass measuring 5.2 x 7.5 x 12 cm extending from the right thyroid lobe to the level of C1. The mass crossed the midline posteriorly. Fine needle aspiration was positive for malignant cells. A core biopsy confirmed diffuse large B-cell lymphoma. The patient had tests for staging, including bone marrow biopsy, and was found to be stage II E diffuse large B-cell lymphoma involving the thyroid. Subsequently, the patient was started on chemotherapy with RCHOP(Rituximab, Cyclophosphamide,Doxorubicin,Vincristine,Prednisolone).

Conclusion

Although Primary thyroid lymphoma (PTL) is a rare condition, it should always be considered in the differential diagnosis of a rapidly growing goiter or thyroid nodule. Its incidence is 2 per million, with nearly all cases the non-Hodgkin’s type. PTL accounts for only 0.5–5% of all thyroid malignancies and 1% to 7% of all extranodal lymphomas. The prevalence of Hashimoto thyroiditis in patients with PTL is highly variable, but patients with HT have a 40- to 80-fold increased risk of developing PTL. A rapidly enlarging neck mass with or without compressive symptoms is the common presentation of PTL. Most common histotype is diffuse large B cell lymphoma which accounts for 50% to 70% of cases. High clinical suspicion and awareness among physicians is needed to diagnose PTL early. The main treatment is chemotherapy. Surgical interventions are needed to relieve pressure symptoms. The prognosis of PTL is generally excellent.
SAT-456 Reduced Cholesterol Absorption and Synthesis Markers in Patients with Hyperthyroidism Due to Graves’ Disease
Authors: Nagamine Tomoko , Inagaki Kyoko , Kobayashi Shunsuke , Shuto Yuki , Nagao Mototsugu , Tamura Hideki , Oikawa Shinichi , Sugihara Hitoshi
Published: May 2020

Background:Thyroid hormones have been reported to promote cell-surface expression of low-density lipoprotein receptor (LDL-R), and also increase mRNA expression of HMG-CoA reductase at the same time. Since LDL cholesterol (LDL-C) uptake via LDL-R is relatively superior to cholesterol synthesis in hyperthyroidism, plasma LDL-C levels can be lower as compared to euthyroid state. Conversely, hypothyroidism can increase plasma LDL-C levels because cholesterol absorption via Niemann-Pick C1-like 1 has been suggested to increase in hypothyroidism. However, there have been no reports about changes of cholesterol absorption and synthesis markers by the treatment of hyperthyroidism in patients with Graves’ disease. Patients and method: We collected plasma samples from patients with hyperthyroidism, who were diagnosed as Graves’ disease (n=17, M/F: 4/13, age: 24-70 years old). Thyroid hormones, general lipid profiles (Total cholesterol: TC, LDL-C, high-density lipoprotein cholesterol: HDL-C and triglyceride: TG), apolipoproteins, markers of cholesterol synthesis (lathosterol) and absorption (campesterol, sitosterol, cholestanol), lipoprotein lipase (LPL), and proprotein convertase subtilisin/kexin type 9 (PCSK9) were analyzed before treatment, and at euthyroid state (eu), 3 and 6 months after attaining euthyroid state (eu-3M and eu-6M). Result: It took 159.2±108.6 days to attain euthyroid state by the thiamazole treatment. TC, LDL-C and HDL-C levels were increased at eu (TC, 144.5±26.7 to 225.0±61.6; LDL-C, 77.8±20.9 to 138.9±43.9; HDL-C, 49.7±12.6 to 67.9±20.0 mg/dL: P<0.0001 vs before treatment, respectively). Such changes remained at eu-3M and eu-6M. TG was not changed at eu, but significantly increased at eu-6M (85.0±49.1 to 113.7±60.8 mg/dL, P=0.02). Cholesterol absorption markers were increased at eu, eu-3M and eu-6M (e.g. campesterol, 2.6±1.2 to 4.9±2.3; sitosterol, 1.5±0.6 to 2.9±1.4; cholestanol, 1.9±0.6 to 3.2±1.1 μg/mL: P<0.0001, eu vs before treatment, respectively). Cholesterol synthesis marker was increased at eu, eu-3M and eu-6M (e.g. lathosterol, 1.8±0.7 to 2.3±0.9 μg/mL: P=0.005, eu vs before treatment). Both LPL and PCSK9 were also increased at eu, eu-3M and eu-6M. Conclusion: These data suggest that both cholesterol absorption and synthesis are downregulated in patients with hyperthyroidism due to Graves’ disease and can be restored by attaining euthyroid state. In turn, LDL-C and TG levels should be carefully monitored during the treatment of Graves’ disease because hyperlipidemia could emerge in euthyroid state.
MON-640 Endogenous Insulin and C-Peptide Suppression Test Using a Rapid-Acting Insulin Analog in the Diagnosis of Insulinoma
Authors: Laotaveerungrueng Nattapong , Lertwattanarak Raweewan , Sriussadaporn Sutin
Published: May 2020

C-peptide suppression test (CPS) was shown to diagnose the cause of hyperinsulinemic hypoglycemia, i.e. insulinoma, as effectively as supervised 72-hour fast test with less time consuming and cost. In the conventional CPS, regular insulin (RI) is used to induce hypoglycemia that subsequently suppresses endogenous insulin secretion. As RI is measurable in plasma insulin (PI) assay, plasma C-peptide (PCP) but not PI response is therefore used for assessment of endogenous insulin secretion in CPS using RI. As rapid acting insulin analogs (RA) are not measurable in a selected PI assay, both PCP and PI levels can be used to assess endogenous insulin secretion if an RA is used instead of RI in CPS. There is no study on PI and PCP responses to RA in insulinoma. This study aimed to examine efficacy of modified CPS, so-called insulin and C-peptide suppression test (ICPS) by using an RA (insulin aspart) in the diagnosis of insulinoma. Ten patients, 7 with histopathological proven insulinoma (IN) and 3 with non-insulinoma (non-IN), underwent ICPS. Blood samples were collected for measurement of plasma glucose (PG), PCP, and PI using a Roche Cobas 8000 module e602 which does not measure insulin aspart at before and every 10-20 minutes during intravenous infusion of insulin aspart at the rate of 0.05-0.075 unit/kg/hr. The test was terminated if the patients had a PG level of <40 mg/dL. There was no difference in baseline biochemical data between two groups. At the end of the test, IN had significantly higher PCP level (range: 0.60-10.20 vs. 0.31-0.48 ng/mL and median: 4.67 vs. 0.47 ng/mL; p = 0.017), lower percentage of PCP suppression (range: 2.10-53.10% vs. 63.08-91.24% and mean: 24.78 ± 19.4% vs. 73.17 ± 15.7%; p = 0.005), higher PI level (range: 1.13-113.70 vs. 0.22-0.73 µIU/mL and median: 21.29 vs. 0.49 µIU/mL; p = 0.017) and lower percentage of PI suppression (range: -14.63-81.32% vs. 88.14-96.10% and mean: 28.45 ± 36.2% vs. 93.31 ± 4.5%; p = 0.003) than did the non-IN. No overlapping of these parameters was observed between IN and non-IN. Using the same cut-off levels as the supervised 72-hour fast test, the insulin criterion (≥3 µIU/mL) in ICPS had a sensitivity of 86% and a specificity of 100% and the C-peptide criterion (≥0.6 ng/mL) in ICPS had a sensitivity of 100% and a specificity of 100%. There was a high correlation of 89% between using PCP and PI responses. In conclusion, ICPS using an RA is effective in the diagnosis of insulinoma.
SAT-010 Non-Classic POR Deficiency as a Cause of Menstrual Disorders & Infertility
Authors: Papadakis Georgios E , Dumont Agathe , Bouligand Jerome , Chasseloup Fanny , Raggi Anna , Catteau-Jonard Sophie , Boute-Benejean Odile , Pitteloud Nelly , Young Jacques , Dewailly Didier R
Published: May 2020

P450 oxidoreductase deficiency (PORD) is an autosomal recessive disease caused by bi-allelic mutations of the POR gene. It is responsible for decreased activity of several P450 enzymes including CYP21A2, CYP17A1 and CYP19A1 that are involved in adrenal and/or gonadal steroidogenesis. PORD is typically diagnosed in neonates and children with ambiguous genitalia and/or skeletal abnormalities. Adult-onset PORD has been very seldom reported and little is known about the optimal way to investigate and treat such patients. In this series, we report five women aged 19-38 years, who were referred for unexplained oligo-/amenorrhea and/or infertility. Genetic testing excluded 21-hydroxylase deficiency (21OH-D), initially suspected due to increased 17-hydroxyprogesterone (17-OHP) levels. Extensive phenotyping, steroid profile by mass spectrometry, pelvic imaging and next-generation sequencing of 84 genes involved in gonadal and adrenal disorders were performed in all patients. In Vitro Fertilization (IVF) followed by frozen embryo transfer under glucocorticoid suppression therapy was performed in two patients. All patients had oligomenorrhea or amenorrhea. None had hyperandrogenism. Low-normal serum estradiol (E2) and testosterone levels contrasted with chronically increased serum progesterone (P) and 17-OHP levels, which further increased after ACTH administration. Despite excessive P, 17OH-P and 21-deoxycortisol rises after ACTH stimulation suggesting non-classic 21-hydroxylase deficiency, CYP21A2 sequencing did not support this hypothesis. Basal serum cortisol levels were low to normal, with inadequate response to ACTH in some women, suggesting partial adrenal insufficiency. Pelvic imaging revealed bilateral ovarian macrocysts in all women. All patients were found to harbor rare bi-allelic POR mutations classified as pathogenic according to American College of Medical Genetics standards. IVF was performed in two women after retrieval of a normal oocyte number despite very low E2 levels during controlled ovarian hyperstimulation. Frozen embryo transfer under glucorticoid suppression therapy led to successful pregnancies. These observations suggest that diagnosis of PORD must be considered in infertile women with chronically elevated P and 17OH-P levels and ovarian macrocysts. Differentiation of this entity from non-classic 21-hydroxylase deficiency is important, as the multiple enzyme deficiency requires a specific management. Successful fertility induction is possible by IVF, providing that P levels be sufficiently suppressed by glucocorticoid therapy prior to implantation.
SAT-554 Genetic Profile of Early-Onset Aldosterone-Producing Adenomas
Authors: Baker Jessica E , Nanba Kazutaka , Blinder Amy R , Bick Nolan , Wachtel Heather , Cohen Debbie L , Williams Tracy Ann , Reincke Martin , Else Tobias , Tomlins Scott A , Giordano Thomas J , Rainey William E
Published: May 2020

Background: Aldosterone-producing adenoma (APA) is a major subtype of primary aldosteronism (PA) which is the most common cause of endocrine-related hypertension. The Endocrine Society clinical practice guideline suggests that young patients (< 35 years old) with a CT-detected adrenocortical adenoma and typical phenotype of PA may not need adrenal venous sampling prior to adrenalectomy. In recent years, aldosterone-driver somatic mutations have been identified in APA, and prevalence studies suggest potential effects of patient age and sex. However, the rare nature of early-onset PA has prevented a detailed study of the histologic characteristics and aldosterone-driver somatic mutations in adrenal tumors from these patients.

Objective: To determine histologic and somatic mutation profile in early-onset APA.

Methods: Fifty-five formalin-fixed paraffin-embedded (FFPE) adrenals from patients at the age of 35 years old or younger who underwent adrenalectomy at the participating centers were studied (45 women, 9 men, and 1 unknown sex). CYP11B2 immunohistochemistry (IHC)-guided tumor capturing was used to selectively obtain DNA from APA. Mutation status was determined either by Sanger sequencing or targeted next-generation sequencing.

Results: CYP11B2 IHC identified APAs in all adrenal specimens. Solitary APAs were found in 53 adrenals. One adrenal had multiple APAs and one had a dominant CYP11B2-negative tumor and a smaller APA. In total, DNA from 57 APAs were sequenced. Two APAs were excluded from the analysis due to low sample quality. In 52 of the 55 APAs, somatic mutations were identified in one of the aldosterone-driver genes or CTNNB1 gene, encoding β-catenin. The most common genetic alteration was seen in KCNJ5 (37/55, 67%), followed by CACNA1D (7/55, 13%), ATP1A1 (3/55, 5%), CTNNB1 (3/55, 5%), and ATP2B3 (2/55, 4%). No sex difference in the prevalence of KCNJ5 mutation was observed in this age group.

Conclusion: The majority of adrenals from early-onset PA patients had a solitary APA. Regardless of sex, the most common genetic cause of early-onset APA was somatic mutations in KCNJ5.
SAT-738 Sources of Error in Estimation of Cortisol Half-Life Using Conventional, Single-Compartment Model: Bias Due to Variation in CBG Concentration
Authors: Fuh Jennifer , Urban Frank , Qualls Clifford , Dorin Richard I
Published: May 2020

Most reports of cortisol half-life in the literature report a range of 90-130 min, which results are based on descriptive model that assumes mono-exponential decay of a single, total cortisol compartment. Free cortisol half-life has been similarly assessed using a descriptive single compartment model (1). However, the descriptive model is not physiologic in view of the rapid exchange between protein-bound and free cortisol compartments and evidence that metabolic elimination is restricted to the free cortisol compartment. In the present study, we sought to explore potential limitations of the descriptive, single-compartment model for cortisol elimination by assessing the influence of CBG concentration ([CBG]) on cortisol half-life estimates obtained using the descriptive model. We studied the influence of [CBG] and other variables on descriptive cortisol half-life using a Monte Carlo simulation of cortisol concentration decay curves developed using data from healthy controls (1). Total cortisol concentration ([TF]) curves were generated on the basis of 4 predictor variables: (i) [CBG], (ii) albumin concentration, (iii) [TF] at time zero following iv bolus (total cortisol at time 0, y-intercept), and (iv) free cortisol half-life central to a mechanistic (dynamic, 3-compartment) model (2). Simulations used a multivariable normal distribution and selected means, SDs, and correlation structure among these 4 variables in healthy controls. After generation of a series of cortisol decay curves (n=1000), half-lives for total and free cortisol were solved using the conventional (descriptive, single-compartment) model. The influence of predictor variables on conventional half-life estimates were assessed using standardized beta (STB) coefficients, which represent change in the SD of the outcome (numerator, i.e. total or free cortisol half-life obtained by descriptive model) for each SD change in a predictor (denominator) in a multivariable context (3). For total cortisol half-life (descriptive model) STBs were 0.91 ([CBG]), 0.73 (free cortisol half-life), -0.37 (y-intercept), and 0.04 ([albumin]) (all P<0.001). For free cortisol half-life (descriptive model), STBs were 0.98 ([CBG]), 0.73 (free cortisol half-life), -0.78 (y-intercept), and 0.11 [albumin]) (all P<0.001). We conclude that the conventional descriptive model for estimation of cortisol has significant limitations, including inaccuracy and systematic bias related to the influence of CBG concentration on half-life estimates. By inference, a similar bias confounds interpretation of the half-life obtained using conventional single-compartment model of other hormones associated with high-affinity serum binding proteins. References: (1) Perogamvros et al. Clin Endo 2011;74:30-36, (2) Keenan et al. Am J Physiol Endocrinol Metab 2004;287:E652-E661 (3) Dorin et al., J Endocrinol Soc 2017 July;1(7):945-56.
OR02-05 Effect of Testosterone Replacement Therapy Added to Intensive Lifestyle Intervention on Cognitive Functions in Frail, Older Veterans with Hypogonadism and Obesity: A Randomized Clinical Trial
Authors: Gregori Giulia , Celli Alessandra , Barnouin Yoann , Paudyal Arjun , Villareal Reina Condevillamar , Quallas Clifford , Villareal Dennis Tan
Published: May 2020

Background: Both hypogonadism and obesity are common in older men which might additively exacerbate their age-related decline in cognitive functions. We tested the hypothesis that the addition of testosterone replacement therapy to intensive lifestyle intervention would enhance the benefits of intensive lifestyle intervention on cognition in older men with hypogonadism and obesity.

Methods: Eighty-three older (age≥65 years) male veterans with obesity (BMI≥30 kg/m2) and evidence of persistently low AM testosterone (<300 ng/dl) associated with frailty (modified Physical Performance Test score <31) were randomized to six months of: 1) lifestyle therapy (diet-induced weight loss and supervised aerobic and resistance exercise training) + testosterone replacement therapy (LT+Test) or 2) lifestyle therapy + placebo (LT+Pbo). In this secondary analyses, outcomes were changes in cognition as assessed through comprehensive cognitive test battery (Modified Mini-Mental State Exam, Word Fluency Test, Trail Making Test Parts A and B Rey Auditory Verbal Learning Test, Stroop Color and Word Test, and Symbol Digit Modalities Test). We used z scores of changes in the cognitive tests to assess changes in attention, memory, executive function, language, global, and composite cognitive functions in response to the lifestyle and hormonal interventions.

Results: After 6 months, body weight decreased similarly in the LT+Test group and LT+Pbo group (decrease of 9.7 kg vs. 10.3 kg, respectively; P=0.91) whereas testosterone levels increased more in the LT+Test than in the LT+Pbo group (increase of 324 ng/dl vs 88 ng/dl, respectively; P<0.001). Memory z-score increased more in the LT+Test group than in the LT+Pbo group (0.73 vs. 0.39, respectively; P=0.03). Moreover, attention z-score increased more in the LT+Test group than in the LT+Pbo group (0.89 vs. 0.38, respectively; P=0.01). On the other hand, changes in executive function z-score, language z-score, and global z-score did not significantly differ between the LT+Test group and LT+Pbo group (0.45 vs 0.37, 0.34 vs 0.07, and 0.55 vs 0.29, respectively; P=0.13 to 0.56). More importantly, the composite cognitive z-score obtained by averaging all z-scores from each domain increased more in the LT+Test group than in the LT+Pbo group (0.56 vs 0.27; P=0.003).

Conclusion: These findings suggest that in the specific population of older men with hypogonadism and obesity associated with frailty, testosterone replacement therapy can augment the positive effects on cognition from intensive lifestyle intervention by diet-induced weight loss and combined aerobic and resistance exercise.
MON-708 Characterizing DNA Methylation Signatures in Adipose Tissue from Metabolic Impaired Asymptomatic Individuals
Authors: Escalante-Araiza Fabiola , Barajas-Olmos Francisco , Martínez-Hernández Angélica , Huerta-Ávila Eira , Peschard Vanessa-Giselle , Rodríguez-Ayala Ernesto , Bastarrachea Raul A , Orozco Lorena
Published: May 2020

Obesity remains as a global epidemic characterized by progressive metabolic dysregulation in glucose homeostasis. Along with a genetic association in the development of T2D, epigenetic regulation has been suggested as a significant contributor in altered gene expression. Recent studies have described DNA methylation changes in insulin-sensitive tissues involved in T2D pathogenesis, however epigenetic dynamics on early stages to metabolic alterations is still unclear.

We investigated potential DNA methylation signatures in 34 asymptomatic individuals from the GEMM family study. We compared differentially methylated CpG sites (DMC: B value>0 and delta Beta >|10%|; Infinium EPIC array) from subcutaneous adipose tissue (SCAT) in different groups of individuals according to BMI (kg/m2) and HbA1c (%) levels as follow: Group A Control (C): n=9, 22.0±1.9 kg/m2, 4.8±0.3%; Group B Overweight (OW) with normal HbA1c: n=6, 27.8±1.6 kg/m2, 5±0.2%; Group C Obese (OB) with normal HbA1c: n=6, 34.6±4.2 kg/m2, 5.2±0.2%; Group D Prediabetes (PD): n=7, 31.1±5.7 kg/m2, 5.9±0.2% and Group E T2D: n=6, 30.6±7.3 kg/m2, 7.2±0.9%.

We found 43 overlapping genes with shared pathways in all groups, mainly those related to metabolism and adipogenesis. We also documented particular altered methylated genes, in each group (OW: 386, OB:1005, PD:76 and T2D:189). Pathway enrichment analysis in OB and T2D was mainly related to glucose metabolism, while in OW and PD was NOTCH signaling. All groups displayed a consistent hypermethylation in RARA, ESR1 and NCOR2, well known genes involved in lipid metabolism. Additionally, we describe for the first time, a progression toward hypomethylation in ARHGAP15 and MTAP, related with an impaired metabolic status. Otherwise, analysis of overlapping CpG sites revealed a consistently hypermethylated state in OW (86.42%), OB (86.48%) and PD (51.72%), in contrast with the hypomethylation state (56.3%) observed in the T2D group, previously observed elsewhere (1).

In conclusion, comparison of methylation in SCAT obtained from OW, OB, PD and T2D individuals, display potential pathways and DMC signatures specific in each group. Common novel overlapping genes in global DNA methylation profiles of SCAT, were also observed.

Reference: (1) Barajas-Olmos et al., BMC Med Genet. 2018 Feb 21;19(1):1-8.

Nothing to Disclose: FE, FB, AM, EH, GEMM, ER, RB, LO.
OR31-04 Androgen Signaling Regulates Female Fertility Through Modulation of H3K27me3 in Granulosa Cells
Authors: Roy Sambit , Sinha Niharika , Huang Binbin , Cline-Fedewa Holly , Wang Jianrong , Sen Aritro
Published: May 2020

Androgens play a major role in female fertility and in women’s health, in general. However, the underlying mechanism and downstream physiological targets of androgen are not fully understood. Androgen actions are mediated by “nuclear” transcriptional signals or “extra-nuclear” kinase actions. Primary androgen receptor (AR) target genes are those at which AR occupies a genomic androgen response element (ARE) and regulates gene transcription. Subsequently, androgens also regulate other genes in an AR-ARE independent fashion, involving membrane-initiated androgen signaling. In the last couple of years, we have reported that androgens may also influence gene expression through histone modifications. We have found that H3K27me3 (tri-methyl lysine 27 histone3) is a downstream target of androgen actions. H3K27me3 is a gene silencing mark, regulated by Enhancer of Zeste Homologue 2 (Ezh2), a histone methyltransferase that promotes tri-methylation of K27 and androgens inhibit the expression and activity of Ezh2. In this study, we report that androgens also regulate the expression of a histone demethylase called Jumonji domain containing protein 3 (JMJD3/KDM6B), that is responsible of removing the H3K27me3 mark. We find that in granulosa cells (GCs), androgen through the PI3K/Akt pathway, in a transcription-independent fashion, increases hypoxia-inducible factor 1 alpha (HIF1α) protein levels, which in turn induce JMJD3 expression. ChIP studies reveal increased binding of HIF1α on the JMJD3 promoter region with DHT treatment. To understand the global impact of androgens on ovarian gene expression and the contribution of androgen-induced decrease of H3K27me3, we have performed RNA-seq and ChIP-seq analysis with H3K27me3 antibody in primary mouse GCs treated with DHT or vehicle. Results show 190 significantly differentially expressed genes in DHT treated sample vs vehicle, out of which 129 and 61 genes were significantly up- and downregulated, respectively. Moreover, comparison of the RNA-seq and ChIP-seq data reveals that a number of upregulated genes have significantly lower H3K27me3 enrichment in the enhancer and/or promoter region in the DHT treated samples vs vehicle. This establishes that in the ovary, androgen-induced modulation of H3K27me3 mark through regulation Ezh2 and JMJD3 expression/activity is an important regulatory mechanism for ovarian gene expression. To delineate the physiological importance of JMJD3 in normal ovarian function and female fertility, we have also developed a GC-specific JMJD3 knockout mice. We find that GC-specific JMJD3KO mice are sub-fertile with longer estrous cycles and dysregulated follicular development. This phenotype is very similar to GC-specific ARKO mice. Thus, we propose that one of the critical actions of androgens in regulating follicular function and female fertility is through the regulation of JMJD3 expression.
SUN-654 Dynamic and Regional Variation of Pancreatic Innervation in Diabetes
Authors: Alvarsson Alexandra , Rosselot Carolina , Jiménez-González Maria , Li Rosemary , Tzavaras Nikolaos , Wu Zhuhao , Stewart Andrew F , Garcia-Ocaña Adolfo , Stanley Sarah A
Published: May 2020

Background: The pancreas is a highly heterogeneous organ, with regional anatomical, developmental and functional differences. The endocrine pancreas is densely innervated, and neural signals play a significant role in glucose regulation by modulating pancreatic hormone release. However, relatively little is known about the anatomical relationships between islets and nerves across the whole pancreas. Since thin filamentous structures, such as nerves, are difficult to quantify and trace over large volumes using thin section histology, there is a need for high resolution imaging and rendering of intact pancreatic tissue in 3D. Aim: To use optical clearing, whole organ imaging, and 3D rendering to quantify islets and innervation across the whole pancreas in healthy mice, in two mouse models of diabetes, and in pancreatic samples from nondiabetic and diabetic human donors. Methods: Whole-mount staining and clearing was performed using iDISCO+ to quantify innervation, defined by the neuronal marker NF200, and beta cells in pancreata from C57Bl/6 mice, non-obese diabetic (NOD) mice, streptozotocin (STZ)-treated mice, and in pancreatic samples from nondiabetic and diabetic human donors. Z-stacked optical sections were acquired with an Ultramicroscope II at 4x or 12x magnification. Imaris was used to create digital surfaces covering the NF200+ innervation and islets to automatically determine innervation density and islet/nerve interactions. Results: Beta cell volumes were 1-4% in the human pancreas, and 1-2% in the healthy mouse pancreas, with regional variations in islet volume and insulin intensity. There were also significant differences in islet biology between the diabetes models. Innervation of the endocrine pancreas was significantly enriched compared to the surrounding exocrine pancreas, with regional variation. Islets were closely associated with pancreatic innervation and decreased in size with increasing distance from nerves in both mouse and human pancreatic tissue. Innervated islets were relatively preserved in models of diabetes. Finally, islet innervation and expression of neural markers were higher in human samples from diabetic patients and in mouse models of diabetes, with temporal and regional differences. Conclusions: 3D imaging and unbiased analysis across the whole pancreas provides comprehensive measurement of pancreatic nerve volumes and distribution. It allows detailed analysis of the anatomical relationship between nerves and islets, and reveals a close association that is maintained across species. The relative enrichment of innervated islets in diabetes and dynamic changes in islet innervation during the development of diabetes suggest further work is needed to examine the role of pancreatic nerves in preserving and protecting beta cells.
OR02-03 Role of Phosphorylated Gonadotropin-Regulated Testicular RNA Helicase (GRTH/DDX25) in the Regulation of Germ Cell Specific MRNAs in Chromatoid Bodies During Spermiogenesis
Authors: Anbazhagan Rajakumar , Kavarthapu Raghuveer , Dufau Maria L
Published: May 2020

Gonadotropin-regulated testicular RNA helicase (GRTH/DDX 25) is a member of the DEAD-box family of RNA helicases which play an essential role in spermatogenesis. There are two species of GRTH, the 56 kDa non-phospho and 61 kDa phospho forms. Our early studies revealed a missense mutation (R242H) of GRTH in the Japanese azoospermic men which resulted in the lack of phospho-GRTH (pGRTH) in in vitro studies. GRTH knock-in (KI) mice with insertion of the human mutant GRTH gene show loss of the cytoplasmic 61 KDa phospho-species with preservation of the non-phospho nuclear form. KI mice are sterile, lack elongated spermatids and spermatozoa with arrest at step 8 of round spermatids (RS) which contain chromatoid bodies (CB) markedly reduced in size. CB is a non-membranous, cytoplasmic organelle present adjacent to the nucleus of RS, where mRNAs bound to GRTH transported from nucleus to cytoplasmic sites are temporarily stored, translationally repressed for later transport to polyribosomes for translation at specific stages of spermiogenesis. Owing to the specific function of CBs and importance of pGRTH in spermatid elongation, CBs isolated from germ cells of WT and GRTH KI mice were used for subsequent experiments. CBs isolated from GRTH KI mice are smaller, highly condensed and lack the nuage texture of CBs in WT mice. We observed the absence of pGRTH in CB of round spermatids of GRTH KI mice. Also, MVH protein (recognized CB marker protein) was decreased in the CB of GRTH KI mice. Expression of genes related to spermatid regulation, chromatin compaction, remodeling (TP1 and 2, PRM1 and 2, GRTH, TSSK6, HMG2, GCNF, RNF8, TDRD 1, 6, 7 and 9) analyzed by qPCR were markedly reduced in the CB of GRTH KI mice compared to WT. No change was observed in the expression of bromodomain mRNAs and protein, indicating that pGRTH does not participate in the translational regulation of this protein class at the level of this organelle. Notably, mRNAs of TP2, PRM2 and GRTH which associated with GRTH protein were co-localized with MVH protein in the CB. This indicated the relevance of GRTH as a binder/transport protein of key chromatin remodelers for ensuring their mRNA repression/stability within the CB. In addition, GRTH binding to genes essential for spermatid development and regulation (TP1 and 2, PRM1 and 2, GRTH, TSSK6, RNF8 and GCNF) were also found to be markedly decreased in the CB KI mice. These results demonstrate the importance of pGRTH in the maintenance of biochemical composition/structure of the CB and role in spermatid regulation, chromatin compaction, spermatid development and completion of spermatogenesis.
SUN-589 MED1 Is a Lipogenesis Coactivator Required for Postnatal Adipose Tissue Expansion
Authors: Jang Younghoon , Tran Nhien , Ge Kai
Published: May 2020

Mediator is a multi-subunit transcription coactivator complex that controls gene activation by connecting enhancer-binding transcription factors (TFs) with RNA polymerase II (Pol II). The Med1 subunit of Mediator is required for PPARγ-stimulated conversion of mouse embryonic fibroblasts to adipocytes in culture. However, it has remained unclear whether MED1 is required for adipose tissue development in vivo. Using Med1 conditional knockout mice, here we report that MED1 is required for postnatal adipose tissue development/expansion, a process that involves dramatic induction of lipogenic enzymes such as SCD1. Mice with Myf5-Cre-mediated MED1 knockout in progenitor cells show normal embryonic development of brown adipose tissue (BAT) but become runts with reduced BAT and white adipose tissue (WAT) after birth. Furthermore, mice with Adipoq-Cre-mediated MED1 knockout in adipocytes show reduced accumulation of lipid droplets and impaired induction of SCD1 in BAT and WAT. These mice display severe lipodystrophy, cold intolerance, and insulin resistance. In culture, Med1 is dispensable for the induction of adipogenesis markers including PPARγ and C/EBPα in the early phase of preadipocyte differentiation. However, Med1 is required for SCD1 induction, lipogenesis and lipid accumulation in the late phase of adipogenesis. Our preliminary data suggest that MED1 controls the induction of SCD1 by facilitating the recruitment of Mediator and subsequently Pol II to active enhancers bound by the lipogenic TF ChREBP. Taken together, our ﬁndings indicate that MED1 is a lipogenesis coactivator required for postnatal adipose tissue expansion.
SUN-364 Enthesophytes Are a Common Feature of FGF23-Mediated Hypophosphatemia Due to Tumor-Induced Osteomalacia
Authors: Gafni Rachel Ilana , Spector Ellen J , Hartley Iris Ruth , Redd Bernadette , Mitnik Gabriela Lopez , Collins Michael T
Published: May 2020

Background: Tumor-induced osteomalacia (TIO) is a rare cause of FGF23-mediated hypophosphatemia in which mesenchymal tumors produce ectopic FGF23, leading to renal phosphate wasting, decreased 1,25-dihydroxy-vitamin D and hypophosphatemia. Clinical features include muscle weakness, fractures and bone pain. Entheses are sites where tendons, ligaments, fasciae and joint capsules attach to bones. Calcifications in entheses, called enthesophytes, are frequent in adults with X-linked hypophosphatemia (XLH), the most common genetic form of FGF23-mediated hypophosphatemia. One study reported 68% of XLH patients having enthesopathies at an average of 18 different insertion sites per person (Polisson, NEJM, 1985). However, the prevalence of enthesophytes in patients with TIO is not known.

Methods: Skeletal surveys of 66 patients with TIO were reviewed by a single radiologist for the presence of enthesophytes, which were then grouped into the following sites: occiput, axial, upper extremities, pelvis/femur, tibia/fibula and feet. The data presented are from the 59 patients (33 men, 26 women) for whom near-complete skeletal surveys were available; feet radiographs were not available in 9 subjects. Descriptive statistics and regression analyses were performed, including analyses of concurrent intact FGF23 and phosphate levels. Data are presented as mean ± SD.

Results: At the time of the skeletal survey, the age of the subjects was 48.7 ± 14.4 years; 78% were over 40 years. The estimated duration of TIO was 6.6 ± 5.3 years. Mean phosphate level was 1.7 ± 0.5 mg/dL (normal 2.5-4.5 mg/dL) and intact FGF23 was 743 ± 1213 pg/mL (normal < 50 pg/mL). Enthesophytes were identified in 51/59 patients (86.4%) with a mean of 4.5 ± 3.7 enthesophytes per patient (range 0-14). The most frequently affected site was the feet (35/50, 70%) followed by occiput (30/59, 51%), pelvis/femur (28/59, 48%), axial (22/59, 37%), upper extremities (18/59, 31%), tibia/fibula (18/59, 17%). In many subjects, more than one enthesophyte was seen within each region - the total number of enthesophytes in the cohort were: feet – 84, pelvis/femur -74, upper extremities – 40, occiput – 30, axial – 23, tibia/fibula – 16. Multiple linear regression demonstrated a significant positive relationship between number of enthesopathies with age and duration of TIO (p < 0.001). Intact FGF23 and phosphate did not significantly correlate with enthesophyte number.

Conclusions: Similar to XLH, these data demonstrate that enthesopathies are a common feature of tumor-induced osteomalacia, increasing with both age and duration of disease. The underlying mechanism of enthesophytes in the general population is unclear and may be related to mechanical forces and/or inflammation. The additional factors of chronic hypophosphatemia and elevated FGF23 likely contribute to this mechanism.
SUN-283 Lithium Induced Partial Nephrogenic Insipidus: An Unusual Presentation
Authors: Akagi Roberto Kenji Mitsui , Olajide Omolola Bolaji
Published: May 2020

Background: Diabetes insipidus (DI) is characterized by hypotonic polyuria and polydipsia. Nephrogenic DI is the result of an inadequate response of the kidneys to arginine vasopressin (AVP), either due to hereditary causes or acquired from various drugs, most commonly lithium. Clinical case: A 30 year old male with past medical history of Hashimoto’s thyroiditis, severe mental impairment was admitted to the hospital for abdominal pain. Medical history was difficult to obtain since the patient was nonverbal. His thyroid function tests, electrolytes including sodium, potassium were all normal on admission. During the hospital course, he was made NPO for both an upper and lower GI endoscopy. He notably had a mild increase in sodium level with subsequent improvement after restitution of diet. Two days after the procedure, he was found to be drinking out of the toilet and also attempting to drink from the urine jug. Due to this odd behavior, he had to be put on physical restraints. The day after, he was found to have a serum sodium of 158 mEq/L. Hypotonic saline was started and urine output was notably ranging from 6-10 L/day with a negative balance. Desmopressin (DDAVP) test was done with a resultant urine osmolality of 170, 237, 257 and 264 mOsm/kg after 30, 60, 90 and 180 mins. Subcutaneous DDAVP was started with some improvement of serum sodium and decrease in urine output. Endocrinology service was consulted for the evaluation of hypernatremia and polyuria. Initial review of his medications did not show any potential cause of DI. Further inquiry of his prior medication history revealed that he had taken Lithium for over 10 years and stopped 4 months prior to the admission due to polyuria. After excluding other causes of polyuria, with partial improvement of urine osmolality to a level <300 mOsm/kg and a clinical history of prior Lithium therapy, a diagnosis of partial nephrogenic DI was made. Patient was started on HCTZ and given adequate water intake with subsequent improvement of his serum sodium back to normal. Conclusion: Nephrogenic DI due to Lithium use usually recovers after treatment is stopped but could be persistent for several years after. In our case, the patient compensated for his polyuria with increased water intake. When his water intake was restricted due to physical restraints, polyuria and subsequently hypernatremia became evident. A thorough medication history including past drug use is essential as it can help unravel the offending agent which was Lithium in our case. There needs to be an increased awareness that the effect of Lithium in the kidneys could be persistent even after stopping the drug for up to many years. References: Thompson CJ. Persistent nephrogenic diabetes insipidus following lithium therapy. Scott Med J 1997; 42:16-17.